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