**6. Valvular disease**

Patients who have received radiation therapy are at risk of long-term cardiovascular toxicity including radiation-induced heart valve disease, pericardial disease and coronary artery disease.

Transthoracic echocardiography is the main tool to identify valvular damage in these patients. There are distinct echocardiographic characteristics of radiotherapyinduced valvular disease. The main distinguishing features between radiotherapyinduced valvular heart disease and rheumatic heart disease are the presence of commissural fusion after radiotherapy, while the involvement of the mitral leaflet tips is an indication of rheumatic disease.

The EACVI and ASE expert consensus statement recommendations for longterm follow-up after radiation therapy suggest a yearly physical examination to assess for symptoms or signs of radiation-induced heart disease, which if present should prompt further evaluation. In asymptomatic patients, a transthoracic echocardiogram is recommended 5 years after exposure in high-risk individuals and 10 years after exposure in all others [24]. High risk individuals are defined the patients who received anterior or left-side chest irradiation and have at least one additional risk factor (smoking, diabetes mellitus, hypertension, hyperlipidemia and obesity).
