medical researchers also realized that treating only small areas originally involved by lymphoma with radiation was not good enough , if radiation had to be used as the only treatment .
a large area covering all lymph node areas in the upper or lower half of the body had to be treated .
when the upper half of the body was being treated , the efrt field was called the  mantle field . 
a high - dose radiation exposure on the thorax is mainly used in the context of adjuvant radiotherapy after conservative or radical breast surgery , adjuvant or exclusive radiotherapy of lung and esophageal cancer , and as a complement to systemic treatment in lymphoma .
irradiation of the heart increases the risk of the so - called  radiation - induced  heart disease ( rihd ) .
the incidence of rihd is 1030% by 510 years posttreatment ; the prevalence of rihd , in the setting of the modern protocols of delivering adjuvant radiotherapy , reduction in doses , and field radiation size , is still poorly defined .
we describe the case of a 66-year - old female with a history of hodgkin 's lymphoma ( type 1a ) treated with mantle radiotherapy in 1973 .
she was admitted for congestive heart failure in radiation - induced heart disease . a cardiac computed tomography angiography ( 64 dual - source , caredose , and electrocardiogram pulsing mindose ) showed calcified ascending aorta and pericardium calcification narrowing the right ventricle , bronchiectasis and fibrosis of the lungs , and esophagus [ figure 1a and b ] . ( a )
multidetector computed tomography short - axis view of the calcification in the ascending aorta and the nearest thickened pericardium , ( b ) multidetector computed tomography long - axis view of the thickened wall of the esophagus a cardiac magnetic resonance imaging ( 1.5 t ) revealed normal left ventricle size ( vts 17 ml , vtsi 10 ml / m ) , with ejection fraction of 0.87 , stroke volume ( sv ) of 70 ml , sv index 39 ml / m , aortic regurgitation and stenosis with aortic valve peak velocity of 163 cm / s and a mild thickness of pericardium ( 3 mm ) and esophagus [ figure 2 ] .
magnetic cardiac imaging ( magnetic resonance imaging ) , axial image demonstrating circumferential thickening of the pericardium ( > 3 mm ) , normal volume of the heart , and calcification of the ascending aorta a transthoracic echocardiography was performed and documented normal ef , aortic regurgitation and aortic stenosis with effective orifice area of 0.78 cmq [ figure 3a and b ] , calcified mitral annulus , signs of constrictive pericarditis ( pericardial calcifications , augmented thickness , and doppler signs of constriction  high filling pressure in the left and right ventricle , annulus paradoxes , and diastolic flow reversal in expiration in the suprahepatic veins ) , and of myocardial damage ( low - tissue doppler velocities at the mitral annulus level [ figure 3c ] , significant pulmonary hypertension [ figure 3d ] ) .
therefore , we wanted to observe better heart and the signs of constrictive pericarditis , so we performed a transesophageal echocardiogram ( tee ) .
surprisingly , we were unable to visualize the cardiac structures because of high and completely acoustic impedance and interfaces [ figure 4 ] .
the acoustic shadowing due to the interface of two different structures with a high level of impedance showed the suboptimal image and no resolution of cardiac structures .
the resultant images were echodense with the lack of signal in the sector beyond the structure [ video 1 ] .
( a ) transthoracic echocardiography view of aortic regurgitation , ( b ) transthoracic echocardiography showing aortic valve stenosis , ( c ) transthoracic echocardiography demonstrating the myocardial damage by low - tissue doppler velocities at the mitral annulus level , ( d ) transthoracic echocardiography showing pulmonary hypertension transesophageal echocardiography failure : the completely impedance to visualize the cardiac structure
radiation therapy uses high - energy rays ( or particles ) to destroy cancer cells . to treat hodgkin 's disease , a carefully focused beam of radiation is delivered from a machine outside of the body .
if the hodgkin 's disease was in the upper body , radiation was given to the mantle field , which included lymph node areas in the neck , chest , and under the arms .
the long - term sequelae of mantle therapy include , especially the lung and cardiac disease but also involve the vessels and the organs in the neck and thorax ( such as thyroid , aorta , and esophagus ) . in our case report ,
the significant thickness of esophagus [ figure 1b ] caused the acoustic impedance due to the inability of tee to view correctly and complete cardiac structure .
any degree of vision or level of depth of the probe did not capture defined images .
the short- and long - term sequelae of mantle field radiation were not predictable and quantifiable and included , especially heart and thoracic structure labeling radiation - induced heart disease . in the literature ,
the descriptions of unavailable tee in a patient with a history of radiation therapy have been few , all of them have pointed out to the rihd or other radiation - induced effects .
our case report emphasized the failure of the tee , in particular , the impedance of radiation - induced thickness of the esophagus hence the unavailability to collect good quality images during the examination
 the long - term sequelae of mantle therapy include , especially lung and cardiac disease but also involve the vessels and the organs in the neck and thorax ( such as thyroid , aorta , and esophagus ) . 
 we presented the case of 66-year - old female admitted for congestive heart failure in radiation - induced heart disease . 
 the patient had undergone to massive radiotherapy 42 years ago for hodgkin 's disease ( type 1a ) . 
 transesophageal echocardiography was performed unsuccessfully with difficulty because of the rigidity and impedance of esophageal walls . 
 our case is an extraordinary report of radiotherapy 's latency effect as a result of dramatic changes in the structure of mediastinum , in particular in the esophagus , causing unavailability of a transesophageal echocardiogram . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION
Financial support and sponsorship
Conflicts of interest
Videos Available on: 