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Hack M, Bhamidipati CM. Management of carcinoid heart disease. Curr Probl Cancer 2024; 52:101128. [PMID: 39173543 DOI: 10.1016/j.currproblcancer.2024.101128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/22/2024] [Indexed: 08/24/2024]
Abstract
Carcinoid Heart Disease (CaHD) is defined as the constellation of all cardiac manifestations that occur in patients with carcinoid tumors. Cardiac manifestations are generally due to the paraneoplastic effects of vasoactive substances secreted by carcinoid tumors. These primarily cause cardiac valve dysfunction and resultant heart failure. Successful management of patients with CaHD requires a multidisciplinary team to address both the classical manifestations of carcinoid syndrome, as well as the additional manifestations of cardiac dysfunction. While the cornerstone of medical management for carcinoid syndrome are somatostatin analogs (SSAs), there is no evidence to suggest that the usage of SSAs influences the development or progression of CaHD. Additionally, while liver-directed therapies provide a survival benefit to symptomatic carcinoid syndrome patients with resectable disease, there are conflicting data on the survival benefit of hepatic resection among patients with CaHD. Cardiac surgery in patients with CaHD is a complex undertaking, and is the only definitive treatment for symptom management in CaHD with significant survival benefit for patients in advanced disease states. Two crucial surgical decisions to be made are determining which valve(s) should be replaced, and what prosthetic should be utilized. While challenging in this often medically frail population, cardiac surgery confers a survival benefit and should be pursued in cases of symptomatic CaHD or progressive right ventricular dysfunction.
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Affiliation(s)
- Madelaine Hack
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | - Castigliano M Bhamidipati
- Division of Cardiothoracic Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
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2
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Namkoong J, Andraweera PH, Pathirana M, Munawar D, Downie M, Edwards S, Averbuj P, Arstall MA. A systematic review and meta-analysis of the diagnosis and surgical management of carcinoid heart disease. Front Cardiovasc Med 2024; 11:1353612. [PMID: 38572311 PMCID: PMC10987853 DOI: 10.3389/fcvm.2024.1353612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/11/2024] [Indexed: 04/05/2024] Open
Abstract
Introduction Carcinoid heart disease (CHD), a complication of carcinoid syndrome (CS), is a rare condition that can lead to right sided valvular heart disease and has been traditionally associated with a poor prognosis. We conducted a systematic review and meta-analysis to explore the accuracy of biomarkers and echocardiography in diagnosing CHD amongst patients who are already known to have neuroendocrine tumours and to assess whether surgical management of CHD leads to a reduction in mortality. Methods A systematic literature search of MEDLINE, EMBASE, EBM Reviews, Google Scholar, ClinicalTrials.gov was conducted. All studies on patients with carcinoid heart disease (CHD) reporting on biomarkers, echocardiographic and surgical outcomes were included. The National Heart, Lung, and Blood Institute quality assessment tool was used to assess the methodological study quality. Data analysis was performed using Stata Statistical Software and R Studio, and individual meta-analyses were performed for biomarkers, echocardiographic findings, and surgical outcomes. Results A total of 36 articles were included in the systematic review analysis. N terminal pro-brain natriuretic peptide (NTproBNP) and 5-hydroxyindole acetate (5-HIAA) levels were higher in patients with CHD compared with those without CHD. 32% of CS patients had echocardiographic evidence of cardiac involvement, of which 79% involved tricuspid valve abnormalities. Moderate-severe tricuspid regurgitation was the most common echocardiographic abnormality (70% of patients). However, these analyses had substantial heterogeneity due to the high variability of cardiac involvement across studies. Pooled surgical mortality for CHD was 11% at 1 month, 31% at 12 months and 56% at 24 months. When assessing surgical outcomes longitudinally, the one-month surgical results showed a trend towards more recent surgeries having lower mortality rates than those reported in earlier years, however this was not statistically significant. Discussion There is not enough data in current literature to determine a clear cut-off value of NTproBNP and 5-HIAA to help diagnose or determine CHD severity. Surgical management of CHD is yet to show significant mortality benefit, and there are no consistent comparisons to medical treatment in current literature.
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Affiliation(s)
- Jenny Namkoong
- Department of Cardiology, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
| | - Prabha H. Andraweera
- Department of Cardiology, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
- Adelaide Medical School, The University of Adelaide, North Terrace Adelaide, SA, Australia
| | - Maleesa Pathirana
- Department of Cardiology, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
- Adelaide Medical School, The University of Adelaide, North Terrace Adelaide, SA, Australia
| | - Dian Munawar
- Department of Cardiology, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
| | - Michael Downie
- SA Health Library Service, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
| | - Suzanne Edwards
- Adelaide Medical School, The University of Adelaide, North Terrace Adelaide, SA, Australia
| | - Paula Averbuj
- Department of Cardiology, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
| | - Margaret A. Arstall
- Department of Cardiology, Lyell McEwin Hospital, SA Health, Elizabeth Vale, SA, Australia
- Adelaide Medical School, The University of Adelaide, North Terrace Adelaide, SA, Australia
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3
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Pavon AG, Guglielmo M. Carcinoid heart disease: another step into the knowledge of a rare disease. Heart 2023; 110:79-80. [PMID: 37553141 DOI: 10.1136/heartjnl-2023-323115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Affiliation(s)
- Anna Giulia Pavon
- Department of Cardiology, Istituto Cardiocentro Ticino, Lugano, Switzerland
| | - Marco Guglielmo
- Department of Cardiology, Division of Heart and Lungs, Utrecht University Medical Center, Utrecht, The Netherlands
- Department of Cardiology, Haga Teaching Hospital, The Hague, The Netherlands
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El Gabry M, Arends S, Shehada SE, Lahner H, Kamler M, Wendt D, Spetsotaki K. Hedinger Syndrome-Lessons Learnt: A Single-Center Experience. J Cardiovasc Dev Dis 2023; 10:413. [PMID: 37887860 PMCID: PMC10607344 DOI: 10.3390/jcdd10100413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 09/26/2023] [Accepted: 09/28/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Hedinger syndrome (HS) or carcinoid heart disease (CD) is a rare and challenging manifestation of malignant neuroendocrine tumours (NETs) involving the heart. We aimed to report our experience with surgical strategies and midterm results in HS patients. METHODS Eleven patients (58 ± 11 (range 41 to 79 years); 5 females) with HS who underwent cardiac surgery in our department between 07/2005 and 05/2023 were analysed. RESULTS All patients showed a New York Heart Association (NYHA) class III-IV and in all the tricuspid valve (TV) was involved. Four patients received a TV replacement, and three TV reconstruction. Recently, to preserve the geometry and function of the compromised right ventricle (RV), we have applied the TV "bio-prosthesis in native-valve" implantation technique with the preservation of the valve apparatus (tricuspid valve implantation: TVI) in four cases. Concomitant procedures included pulmonary valve replacement in four, pulmonary implantation in one, and aortic valve replacement in three cases. To treat RV failure, we adapted a combined TandemHeart®-CytoSorb® haemoperfusion strategy in Patient #10 and venoarterial extracorporeal membrane oxygenation (V-A ECMO) support avoidance, after experiencing an ECMO-induced carcinoid-storm-related death in Patient #8. Mortality at 30 days was 18% (2/11). The median follow up was 2 ± 2.1 years (range 1 month to 6 years) with an overall mortality during the follow-up period of 72.7% (8/11). CONCLUSIONS HS surgery, despite being a high-risk procedure, can efficiently prolong survival, and represents a safe and feasible procedure. However, patient selection seems to be crucial. Further follow up and larger cohorts are needed.
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Affiliation(s)
- Mohamed El Gabry
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre, 45147 Essen, Germany; (M.E.G.); (M.K.); (D.W.)
| | - Sven Arends
- Department for Anesthesiology and Intensive Care Medicine, University of Duisburg-Essen, 45147 Essen, Germany;
| | - Sharaf-Eldin Shehada
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre, 45147 Essen, Germany; (M.E.G.); (M.K.); (D.W.)
| | - Harald Lahner
- Department of Endocrinology and Metabolism, University Hospitals Duisburg-Essen, 45147 Essen, Germany;
| | - Markus Kamler
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre, 45147 Essen, Germany; (M.E.G.); (M.K.); (D.W.)
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre, 45147 Essen, Germany; (M.E.G.); (M.K.); (D.W.)
- CytoSorbents Europe GmbH, 12587 Berlin, Germany
| | - Konstantina Spetsotaki
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre, 45147 Essen, Germany; (M.E.G.); (M.K.); (D.W.)
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Meir J, Michaud L, Frishman WH, Aronow WS. The Past, Present, and The Future of Carcinoid Heart Disease. Cardiol Rev 2023; 31:193-198. [PMID: 36515580 DOI: 10.1097/crd.0000000000000475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Carcinoid heart disease is a frequent manifestation of carcinoid syndrome. It results from the release of a large amount of serotonin and subsequently fibrosis of right sided heart valves, that is, tricuspid and pulmonic valve. This article reviews the pathogenesis, clinical symptoms, diagnosis, treatment and prognosis of carcinoid heart disease. Recent developments in treating carcinoid heart disease have improved the poor prognosis associated with the disease.
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Affiliation(s)
- Juliet Meir
- From the Departments of Cardiology and Medicine, Westchester Medical Center and New York Medical College, Vaslhalla, NY
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Konsek-Komorowska SJ, Pęczkowska M, Kolasińska-Ćwikła AD, Cichocki A, Konka M, Roszkowska-Purska K, Ćwikła JB. Analysis of Patients with NET G1/G2 Neuroendocrine Tumors of the Small Intestine in the Course of Carcinoid Heart Disease-A Retrospective Study. J Clin Med 2023; 12:jcm12030790. [PMID: 36769439 PMCID: PMC9918269 DOI: 10.3390/jcm12030790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
Neuroendocrine neoplasms of the small intestine (SI-NENs) are one of the most commonly recognized gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs). Carcinoid heart disease (CHD) is the primary cause of death in patients with the carcinoid syndrome (CS). The aim of this retrospective study was to evaluate possible factors impacting upon overall survival (OS) in subjects with both neuroendocrine tumors (NETs) G1/G2 of the small intestine (SI-NET) and CHD. Enrolled in our study of 275 patients with confirmed G1/G2 SI-NET, were 28 (10%) individuals with CHD. Overall survival was assessed using the Kaplan-Meier method. The Cox-Mantel test was used to determine how OS varied between groups. A Cox proportional hazards model was used to conduct univariate analyses of predictive factors for OS and estimate hazard ratios (HRs). Of the 28 individuals with confirmed carcinoid heart disease, 12 (43%) were found to have NET G1 and 16 (57%) were found to have NET G2. Univariate analysis revealed that subjects with CHD and without resection of the primary tumor had a lower OS. Our retrospective study observed that patients who presented with CHD and without resection of primary tumor had worse prognosis of survival. These results suggest that primary tumors may need to be removed when feasible, but further research is needed. However, no solid recommendations can be issued on the basis of our single retrospective study.
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Affiliation(s)
- Sonia J. Konsek-Komorowska
- Department of Cardiology and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-082 Olsztyn, Poland
- Correspondence:
| | - Mariola Pęczkowska
- The Cardinal Stefan Wyszyński National Institute of Cardiology, 04-628 Warsaw, Poland
| | | | - Andrzej Cichocki
- The Maria Sklodowska-Curie National Research Institute of Oncology, 02-034 Warsaw, Poland
| | - Marek Konka
- The Cardinal Stefan Wyszyński National Institute of Cardiology, 04-628 Warsaw, Poland
| | | | - Jarosław B. Ćwikła
- Department of Cardiology and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, 10-082 Olsztyn, Poland
- Diagnostic and Therapeutic Center–Gammed, 02-351 Warsaw, Poland
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Honan KA, Hassan S, Deswal A, Herrmann J, Song J, Monlezun D, Halperin D, Mahvash A, Dasari A, Koutroumpakis E, Akay M, Balanescu DV, de Armas IS, Patel M, Nathan S, Kar B, Marmagkiolis K, Lopez-Mattei J, Patel J, Gregoric I, Yao J, Iliescu CA. Bioprosthetic valve monitoring in patients with carcinoid heart disease. Front Cardiovasc Med 2023; 9:1072890. [PMID: 36712267 PMCID: PMC9878394 DOI: 10.3389/fcvm.2022.1072890] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/22/2022] [Indexed: 01/14/2023] Open
Abstract
Background Carcinoid heart disease (CnHD) is a frequent cause of morbidity and mortality in patients with neuroendocrine tumors and carcinoid syndrome. Although valve replacement surgery appears to decrease all-cause mortality in patients with advanced CnHD, few studies have investigated the outcomes of patients after valve replacement. Methods We conducted a multi-institution retrospective registry of patients who received both tricuspid and pulmonic bioprosthetic valve (TV/PV) replacements for advanced CnHD from November 2005 to March 2021. Patients were followed post-operatively with echocardiographic studies every 3 months. Carcinoid valvular heart disease scores were used to monitor valve degeneration. Neuroendocrine tumor treatment, their administration times, and associations with echocardiographic findings were recorded. Results Of 87 patients with CnHD, 22 patients underwent simultaneous surgical TV and PV replacement. In 6 patients (27.3%), increased PV Vmax was the first echocardiographic manifestation of valve degeneration in the setting of occult neurohormonal release. Post-operative telotristat ethyl and peptide receptor radionuclide therapy appeared to stabilize PV Vmax. The PV Vmax showed consistent elevation in the entire patient population when compared to baseline, while bioprosthetic TV echocardiographic parameters were relatively unchanged throughout. Post-operative warfarin therapy did not affect the rate of PV degeneration, and no major bleeding was recorded during or after post-operative anticoagulation therapy. Conclusion Bioprosthetic valve degeneration is common in CnHD. Monitoring with echocardiographic studies every 3 months, focusing on PV velocities, could identify patients with occult disease that very likely promotes valve degeneration. Novel neuroendocrine tumor therapies may have a beneficial impact on valve degeneration.
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Affiliation(s)
- Kevin A. Honan
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Saamir Hassan
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Anita Deswal
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, United States
| | - Juhee Song
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Dominique Monlezun
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Daniel Halperin
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Armeen Mahvash
- Division of Diagnostic Imaging, Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Arvind Dasari
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Efstratios Koutroumpakis
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Mehmet Akay
- Department of Cardiothoracic Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Dinu-Valentin Balanescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Ismael Salas de Armas
- Department of Cardiothoracic Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Manish Patel
- Department of Cardiothoracic Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Sriram Nathan
- Center for Advanced Heart Failure, Memorial Hermann Hospital, Heart and Vascular Institute, Texas Medical Center, Houston, TX, United States
| | - Biswajit Kar
- Center for Advanced Heart Failure, Memorial Hermann Hospital, Heart and Vascular Institute, Texas Medical Center, Houston, TX, United States
| | - Konstantinos Marmagkiolis
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Juan Lopez-Mattei
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jay Patel
- Department of Cardiothoracic Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Igor Gregoric
- Department of Cardiothoracic Surgery, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, United States
| | - James Yao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Cezar A. Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States,*Correspondence: Cezar A. Iliescu,
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Balancing carcinoid crisis and right ventricular dysfunction during tricuspid and pulmonic valve replacement for carcinoid heart disease: A case report. Int J Surg Case Rep 2023; 102:107855. [PMID: 36610355 PMCID: PMC9829749 DOI: 10.1016/j.ijscr.2022.107855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/19/2022] [Accepted: 12/29/2022] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION AND IMPORTANCE Carcinoid tumors are rare malignancies of neuroendocrine origin that can manifest with a constellation of systemic symptoms including right-sided cardiac involvement. Many patients with carcinoid heart disease require valve replacement, but intraoperative management of carcinoid syndrome varies within the literature. CASE PRESENTATION A 72-year-old man with carcinoid syndrome underwent tricuspid and pulmonic valve replacement with multiple episodes of carcinoid crisis intraoperatively as well as right ventricular dysfunction after cardiopulmonary bypass. CLINICAL DISCUSSION Octreotide is the mainstay in prevention and treatment of intraoperative carcinoid crisis, but reported dosages and timing varies significantly. The use of exogenous catecholamines is also controversial as they are thought to paradoxically worsen carcinoid symptoms. Our patient was managed successfully with both an octreotide infusion and intermittent boluses, as well as exogenous catecholamines for right ventricular support during and after cardiopulmonary bypass. CONCLUSION The management of carcinoid syndrome in patients undergoing valve surgery for carcinoid heart disease is dependent on timely prevention and treatment of carcinoid crisis and effective mitigation of right ventricular dysfunction.
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Lopez-Mattei J, Yang EH, Baldassarre LA, Agha A, Blankstein R, Choi AD, Chen MY, Meyersohn N, Daly R, Slim A, Rochitte C, Blaha M, Whelton S, Dzaye O, Dent S, Milgrom S, Ky B, Iliescu C, Mamas MA, Ferencik M. Cardiac computed tomographic imaging in cardio-oncology: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT). Endorsed by the International Cardio-Oncology Society (ICOS). J Cardiovasc Comput Tomogr 2023; 17:66-83. [PMID: 36216699 DOI: 10.1016/j.jcct.2022.09.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 09/01/2022] [Accepted: 09/12/2022] [Indexed: 11/21/2022]
Abstract
Cardio-Oncology is a rapidly growing sub-specialty of medicine, however, there is very limited guidance on the use of cardiac CT (CCT) in the care of Cardio-Oncology patients. In order to fill in the existing gaps, this Expert Consensus statement comprised of a multidisciplinary collaboration of experts in Cardiology, Radiology, Cardiovascular Multimodality Imaging, Cardio-Oncology, Oncology and Radiation Oncology aims to summarize current evidence for CCT applications in Cardio-Oncology and provide practice recommendations for clinicians.
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Affiliation(s)
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Ali Agha
- Department of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Ron Blankstein
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Andrew D Choi
- Division of Cardiology and Department of Radiology, The George Washington University School of Medicine, Washington, DC, USA
| | - Marcus Y Chen
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Nandini Meyersohn
- Division of Cardiovascular Imaging, Department of Radiology, Massachusetts General Hospital, USA
| | - Ryan Daly
- Franciscan Health Indianapolis, Indianapolis, IN, USA
| | | | - Carlos Rochitte
- InCor Heart Institute, University of São Paulo Medical School, São Paulo, Brazil
| | - Michael Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Seamus Whelton
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Omar Dzaye
- Johns Hopkins Ciccarone Center for the Prevention of Cardiovascular Disease, Baltimore, MD, USA
| | - Susan Dent
- Duke Cancer Institute, Department of Medicine, Duke University, Durham, NC, USA
| | - Sarah Milgrom
- Department of Radiation Oncology, University of Colorado, Boulder, CO, USA
| | - Bonnie Ky
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Cezar Iliescu
- Heart and Vascular Institute, Lee Health, Fort Myers, FL, USA
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Keele University, UK
| | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
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Șerban A, Dădârlat-Pop A, Tomoaia R, Hagiu C, Axente D, Donca V, Suceveanu M. The Role of Echocardiography in the Diagnosis of Cardiac Involvement in a Rare Systemic Condition: The Carcinoid Heart Disease: A Case Report and Review of Literature. Diagnostics (Basel) 2022; 12:diagnostics12122929. [PMID: 36552936 PMCID: PMC9776767 DOI: 10.3390/diagnostics12122929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/19/2022] [Accepted: 11/20/2022] [Indexed: 11/25/2022] Open
Abstract
Carcinoid heart disease is a rare presentation of the carcinoid syndrome, which is caused by excessive tumoral hormone production and the abundant release of vasoactive substances with systemic expressions. A 62-year-old woman presented with flushing, diarrhea, weight loss, and right-sided heart failure symptoms. Specific carcinoid heart disease features were identified using transthoracic and transesophageal echocardiography at the tricuspid and pulmonic valves. Biomarkers, 99mTc-Tektrotyd scintigraphy, SPECT-CT, and a biopsy later confirmed the diagnosis, and the patient began treatment for the underlying condition.
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Affiliation(s)
- Adela Șerban
- Cardiology Department, Heart Institute Niculae Stăncioiu, 19-21 Motilor Street, 400001 Cluj-Napoca, Romania
- 5th Department of Internal Medicine, Faculty of Medicine, Iuliu Haţieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
| | - Alexandra Dădârlat-Pop
- Cardiology Department, Heart Institute Niculae Stăncioiu, 19-21 Motilor Street, 400001 Cluj-Napoca, Romania
- 5th Department of Internal Medicine, Faculty of Medicine, Iuliu Haţieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- Correspondence:
| | - Raluca Tomoaia
- 5th Department of Internal Medicine, Faculty of Medicine, Iuliu Haţieganu University of Medicine and Pharmacy, 8 Victor Babes Street, 400012 Cluj-Napoca, Romania
- Clinical Rehabilitation Hospital, 46-50 Viilor Street, 400347 Cluj-Napoca, Romania
| | - Claudia Hagiu
- 3rd Medical Department, “Iuliu Hatieganu” University of Medicine and Pharmacy, 400347 Cluj-Napoca, Romania
- “Prof. Dr. Octavian Fodor” Regional Gastroenterology-Hepatology Institute, 400394 Cluj-Napoca, Romania
| | - Dan Axente
- Cluj-Napoca Municipal Clinical Hospital, 400139 Cluj-Napoca, Romania
| | - Valer Donca
- Cluj-Napoca Municipal Clinical Hospital, 400139 Cluj-Napoca, Romania
| | - Mihai Suceveanu
- Cardiology Department, Heart Institute Niculae Stăncioiu, 19-21 Motilor Street, 400001 Cluj-Napoca, Romania
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Dreyfus J, Dreyfus GD, Taramasso M. Tricuspid valve replacement: The old and the new. Prog Cardiovasc Dis 2022; 72:102-113. [PMID: 35738423 DOI: 10.1016/j.pcad.2022.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 06/12/2022] [Indexed: 11/29/2022]
Abstract
Tricuspid regurgitation is a frequent and serious condition but tricuspid valve (TV) surgery, that may be a valve replacement when a repair is not feasible, is rarely performed. Recent development of transcatheter TV interventions offers new options for those high-surgical risk patients, especially TV replacement for patients who are not eligible for transcatheter TV repair. In this review, we describe indications and outcome after surgical TV replacement, and devices available or in development for transcatheter TV replacement.
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Affiliation(s)
- Julien Dreyfus
- Cardiology Department, Centre Cardiologique du Nord, Saint-Denis, France.
| | - Gilles D Dreyfus
- Department of Cardiac Surgery, Montsouris Institute, Paris, France
| | - Maurizio Taramasso
- Cardiovascular Surgical Department, University Hospital of Zurich, Zurich, Switzerland
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12
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The prevalence, operations, and outcomes of carcinoid heart disease. Am J Surg 2022; 224:665-669. [DOI: 10.1016/j.amjsurg.2022.03.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/08/2022] [Accepted: 03/28/2022] [Indexed: 11/18/2022]
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Outcomes and periprocedural management of cardiac implantable electronic devices in patients with carcinoid heart disease. Heart Rhythm 2021; 18:2094-2100. [PMID: 34428559 DOI: 10.1016/j.hrthm.2021.08.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/12/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Carcinoid heart disease (CHD) is a rare complication of hormonally active neuroendocrine tumors that often requires surgical intervention. Data on cardiac implantable electronic device (CIED) implantation in patients with CHD are limited. OBJECTIVE The purpose of this study was to evaluate the experience of CIED implantation in patients with CHD. METHODS Patients with a diagnosis of CHD and a CIED procedure from January 1, 1995, through June 1, 2020, were identified using a Mayo Clinic proprietary data retrieval tool. Retrospective review was performed to extract relevant data, which included indications for implant, procedural details, complications, and mortality. RESULTS A total of 27 patients (55.6% male; mean age at device implant 65.6 ± 8.8 years) with cumulative follow-up of 75 patient-years (median 1.1 years; interquartile range 0.4-4.6 years) were included for analysis. The majority of implanted devices were dual-chamber permanent pacemakers (63%). Among all CHD patients who underwent any cardiac surgery, the incidence of CIED implantation was 12%. The most common indication for implantation was high-grade heart block (66.7%). Device implant complication rates were modest (14.8%). No patient suffered carcinoid crisis during implantation, and there was no periimplant mortality. Median time from implant to death was 2.5 years, with 1-year mortality of 15%. CONCLUSION CHD is a morbid condition, and surgical valve intervention carries associated risks, particularly a high requirement for postoperative pacing needs. Our data suggest that CIED implantation can be performed relatively safely. Clinicians must be aware of the relevant carcinoid physiology and take appropriate precautions to mitigate risks.
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14
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Bergsten J, Flachskampf FA, Lundin L, Öhagen P, Albåge A. A 33-year follow-up after valvular surgery for carcinoid heart disease. Eur Heart J Cardiovasc Imaging 2021; 23:524-531. [PMID: 33899077 DOI: 10.1093/ehjci/jeab049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/12/2021] [Indexed: 12/21/2022] Open
Abstract
AIMS Valvular surgery has improved long-term prognosis in severe carcinoid heart disease (CaHD). Experience is limited and uncertainty remains about predictors for survival and strategy regarding single vs. double-valve surgery. The aim was to review survival and echocardiographic findings after valvular surgery for CaHD at our institution. METHODS AND RESULTS Between 1986 and 2019, 60 consecutive patients, median age 64 years, underwent valve surgery for severe CaHD. Operations involved combined tricuspid valve replacement (TVR) and pulmonary valve replacement (PVR) in 42 cases, and TVR-only or TVR with pulmonary valvotomy (no PVR) in 18 patients. All implanted valves were bioprosthetic. Preoperative echocardiography, creatinine, NT-pro-brain natriuretic peptide (NT-pro-BNP), and 24-h urinary 5-hydroxyindoleacetic acid (5-HIAA) were obtained. 30-Day mortality was 12% (n=7), and 8% for the most recent decade 2010-2019. Median survival was 2.2 years and maximum survival 21 years. Patients undergoing combined TVR and PVR had significantly higher survival compared with operations without PVR (median 3.0 vs. 0.9 years, P = 0.02). Preoperative levels of NT-pro-BNP and 5-HIAA in the top quartile predicted poor survival. On preoperative echocardiograms, pulmonary regurgitation was severe in 51% and indeterminate in 17%. Postoperative echocardiography confirmed relatively good durability of bioprostheses, relative to the patients' limited oncological life expectancy. CONCLUSION Valvular surgery in CaHD has an acceptable perioperative risk. Survival for combined TVR and PVR was significantly higher compared with operations without PVR. Bioprosthetic valve replacement appears to have adequate durability. Preoperative echocardiography may underestimate pulmonary pathology. Combined TVR and PVR should be considered in most patients.
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Affiliation(s)
- Johannes Bergsten
- Department of Clinical Physiology and Cardiology, University Hospital, Uppsala, Sweden.,Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Frank A Flachskampf
- Department of Clinical Physiology and Cardiology, University Hospital, Uppsala, Sweden.,Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Lennart Lundin
- Department of Clinical Physiology and Cardiology, University Hospital, Uppsala, Sweden.,Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Patrik Öhagen
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Anders Albåge
- Department of Cardiothoracic Surgery and Anesthesiology, University Hospital, Uppsala, Sweden.,Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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15
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Chan DL, Pavlakis N, Crumbaker M, Lawrence B, Barber C, Price TJ, Michael M, Oberg K. Vigilance for carcinoid heart disease is still required in the era of somatostatin analogues: Lessons from a case series. Asia Pac J Clin Oncol 2021; 18:209-216. [PMID: 33852771 DOI: 10.1111/ajco.13577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 02/05/2021] [Indexed: 11/30/2022]
Abstract
AIM Carcinoid heart disease (CHD) is a well-documented complication of neuroendocrine tumors (NETs) due to secreted hormones causing fibrosis. Somatostatin analogues (SSAs) can decrease hormonal secretion and inhibit tumor growth. The reported incidence of CHD has decreased as SSA use has increased. We describe a series of patients who have developed CHD even though they were treated with SSA therapy. METHODS Nine patients were seen in four centers in Australia and New Zealand. The average duration of follow-up from diagnosis was 39 months. RESULTS Three patients had Grade 1 and six Grade 2 disease by World Health Organization 2010 criteria. All patients had no CHD symptoms at baseline and started SSA therapy soon after diagnosis, yet developed significant, symptomatic cardiac dysfunction in their disease course. The median time from NET diagnosis to SSA initiation was 1 month, and median time from NET diagnosis to CHD diagnosis was 23 months (range 4-52). All patients who were tested had persistently increased hormonal levels (chromogranin A, urinary 5-hydroxyindolacetic acid). CONCLUSIONS The good symptomatic control afforded by SSAs should not lead to reduced vigilance in screening for CHD, especially in patients with persistently elevated hormonal assays. Clinicians should consider regular echocardiographic screening in patients with a secretory syndrome.
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Affiliation(s)
- David L Chan
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia.,Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Nick Pavlakis
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia.,Northern Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Megan Crumbaker
- Department of Medical Oncology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Ben Lawrence
- Discipline of Oncology, University of Auckland, Auckland, New Zealand
| | - Camilla Barber
- The School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Timothy J Price
- Department of Medical Oncology, The Queen Elizabeth Hospital and University of Adelaide, Adelaide, SA, Australia
| | - Michael Michael
- Division of Cancer Medicine & Neuroendocrine Unit, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Kjell Oberg
- Department of Endocrine Oncology, University Hospital, Uppsala, Sweden
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16
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O'Malley TJ, Jimenez DC, Saxena A, Weber MP, Samuels LE, Entwistle JW, Guy TS, Massey HT, Morris RJ, Tchantchaleishvili V. Outcomes of surgical treatment for carcinoid heart disease: A systematic review and meta-analysis. Surgery 2021; 170:390-396. [PMID: 33812754 DOI: 10.1016/j.surg.2021.02.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 02/15/2021] [Accepted: 02/22/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Carcinoid heart disease (CaHD) develops from vasoactive substances released by neuroendocrine tumors, which can cause significant patient morbidity and mortality without surgical intervention. We performed a systematic review and meta-analysis to elucidate granular perioperative details and long-term outcomes in these patients. METHODS Electronic search of Ovid, Scopus, Cumulative Index of Nursing and Allied Health Literature, and Cochrane Controlled Trials Register was performed to examine surgical treatment of carcinoid disease. Nine articles comprising 416 patients were selected. Study-level data were extracted and pooled for meta-analysis. RESULTS Mean patient age was 63 years (95% confidence interval, 57-70) with 53% (95% confidence interval, 46-61) of patients being male. In addition, 75% (95% confidence interval, 54-96) of neuroendocrine tumors originated from the small bowel or colon and 98% (95% confidence interval, 93-100) had liver metastases. Right heart failure was present in 48% (95% confidence interval, 14-81). Moderate or severe regurgitation was present in 97% (95% confidence interval, 95-99) of tricuspid and 72% (95% confidence interval, 58-83) of pulmonary valves. In addition, 99% (95% confidence interval, 98-100) of tricuspid and 59% (95% confidence interval, 38-79) of pulmonary valves were replaced. Bioprosthetic valves were used in 80% (95% confidence interval, 68-93) of tricuspid positions. Mean hospital duration of stay was 16 days (95% confidence interval, 7-25). Thirty-day mortality was 9% (95% confidence interval, 6-12). Mean follow-up was 25 months (95% confidence interval, 11-39). Median survival was 3 years (95% confidence interval, 2.5-3.5). CONCLUSION For patients >18 years of age, surgical treatment of carcinoid heart disease can be performed with a reasonable safety profile. However, overall survival appears to have ongoing effects of the primary disease.
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Affiliation(s)
- Thomas J O'Malley
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Diana C Jimenez
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Abhiraj Saxena
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Matthew P Weber
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Louis E Samuels
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
| | - John W Entwistle
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
| | - T Sloane Guy
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
| | - H Todd Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
| | - Rohinton J Morris
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, PA
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17
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Timing of peptide receptor radiotargeted therapy in relation to cardiac valve surgery for carcinoid heart disease in patients with neuroendocrine metastases and cardiac syndrome. A single-centre study from a centre of excellence. Nucl Med Commun 2021; 41:575-581. [PMID: 32371675 DOI: 10.1097/mnm.0000000000001200] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Perioperative mortality of patients who undergo heart valve surgery for carcinoid heart valve disease has been observed to be high (5%-10%). We investigated whether peptide receptor radiotherapy with lutetium-177 dotatate can be used safely in patients with neuroendocrine neoplasm carcinoid heart valve disease and if there is associated survival advantage by reducing overall exposure of the valves to high doses of vasoactive peptides. METHOD Retrospective case notes review was performed on 18 neuroendocrine neoplasm patients (mean 60 years), who underwent heart valve surgery between 2003 and 2017 for carcinoid heart valve disease, 9 of whom received peptide receptor radiotherapy in addition to surgery. RESULTS All patients were treated with somatostatin receptor antagonists and underwent cardiac valvular surgery (mean two valves replaced) and three benefitted from additional coronary bypass grafting. Nine patients underwent surgery alone: in this group, the time from surgery to progression was 14 months (mean; SD 13.5 months). Nine were treated with peptide receptor radiotherapy in addition to surgery. Six underwent surgery with peptide receptor radiotherapy on progression. Time to progression from surgery to first peptide receptor radiotherapy was mean 25.1 months (SD 23.6 months). No patients developed peritreatment cardiac complications. There were no deaths within the 30-day postoperative period. Average time from surgery to last follow-up/death was 41 months (6-79) in the surgery + lutetium group and in the surgery only group 17 months (1-24). Nine patients died, five in the surgery + lutetium group and four in the surgery only group, all at greater than 1-year postsurgery. DISCUSSION Peptide receptor radiotherapy is safe in the setting of Carcinoid valvular heart disease in patients with controlled heart failure, PPRT can be use in the pre- and post-valve surgery period. There appears to be a survival benefit of having peptide receptor radiotherapy. Further evidence for peptide receptor radiotherapy in the neoadjuvant setting prior to cardiothoracic surgery is required.
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18
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Buchanan-Hughes A, Pashley A, Feuilly M, Marteau F, Pritchard DM, Singh S. Carcinoid Heart Disease: Prognostic Value of 5-Hydroxyindoleacetic Acid Levels and Impact on Survival: A Systematic Literature Review. Neuroendocrinology 2021; 111:1-15. [PMID: 32097914 DOI: 10.1159/000506744] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/23/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Carcinoid heart disease (CHD) can develop in patients with carcinoid syndrome (CS), itself caused by overproduction of hormones and other products from some neuroendocrine tumours. The most common hormone is serotonin, detected as high 5-hydroxyindoleacetic acid (5-HIAA). This systematic literature review summarises current literature on the impact of CHD on survival, and the relationship between 5-HIAA levels and CHD development, progression, and mortality. METHODS MEDLINE, Embase, Cochrane databases, and grey literature were searched using terms for CHD, 5-HIAA, disease progression, and mortality/survival. Eligible articles were non-interventional and included patients with CS and predefined CHD and 5-HIAA outcomes. RESULTS Publications reporting on 31 studies were included. The number and disease states of patients varied between studies. Estimates of CHD prevalence and incidence among patients with a diagnosis/symptoms indicative of CS were 3-65% and 3-42%, respectively. Most studies evaluating survival found significantly higher mortality rates among patients with versus without CHD. Patients with CHD reportedly had higher 5-HIAA levels; median urinary levels in patients with versus without CHD were 266-1,381 versus 67.5-575 µmol/24 h. Higher 5-HIAA levels were also found to correlate with disease progression (median progression/worsening-associated levels: 791-2,247 µmol/24 h) and increased odds of death (7% with every 100 nmol/L increase). CONCLUSIONS Despite the heterogeneity of studies, the data indicate that CHD reduces survival, and higher 5-HIAA levels are associated with CHD development, disease progression, and increased risk of mortality; 5-HIAA levels should be carefully managed in these patients.
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19
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Dherange P, Telles N, Modi K. Flow-driven right-to-left cardiac shunting in a patient with carcinoid heart disease and patent foramen ovale without elevated right atrial pressure: a case report and literature review. Eur Heart J Case Rep 2020; 4:1-5. [PMID: 33442599 PMCID: PMC7793043 DOI: 10.1093/ehjcr/ytaa301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 10/10/2018] [Accepted: 08/06/2020] [Indexed: 11/14/2022]
Abstract
Background Carcinoid heart disease is present in approximately 20% of the patients with carcinoid syndrome and is associated with poor prognosis. It usually manifests with right-sided valvular involvement including tricuspid insufficiency and pulmonary stenosis. Patent foramen ovale (PFO) is present in approximately 50% of the patients with carcinoid heart disease which is twice higher than the general population. Right-to-left shunting through a PFO can occur either due to higher right atrial pressure than left (pressure-driven) or when the venous flow is directed towards the PFO (flow-driven) in the setting of normal intracardiac pressures. We report a rare case of flow-driven right-to-left atrial shunting via PFO in a patient with carcinoid heart disease. Case summary A 54-year-old male with a metastatic neuroendocrine tumour to liver presented with progressive shortness of breath for 5 months. Patient was found to be hypoxic with oxygen saturation of 78% and examination revealed a holosystolic murmur. Arterial blood gas showed oxygen tension of 43 mmHg. A transthoracic and transoesophageal echocardiogram showed aneurysmal inter-atrial septum with a PFO, severe tricuspid regurgitation directed anteriorly towards the inter-atrial septum leading to a marked right-to-left shunt. Right heart catheterization showed right atrial pressure of 8 mmHg, mean pulmonary artery pressure of 12 mmHg, and normal oxygen saturations in the right atrium, right ventricle, and pulmonary arteries. The patient then underwent closure of the PFO along with tricuspid valve and pulmonary valve replacement at an experienced cardiovascular surgical centre and has been asymptomatic since. Conclusion Right-to-left shunting through a PFO in patients with normal right atrial pressure can be successfully treated with closure of the PFO. Thus, understanding the mechanism of intracardiac shunts is important to accurately diagnose and treat this rare and fatal condition.
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Affiliation(s)
- Parinita Dherange
- Department of Cardiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, USA
| | - Nelson Telles
- Department of Cardiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, USA
| | - Kalgi Modi
- Department of Cardiology, Louisiana State University Health Sciences Center at Shreveport, Shreveport, LA, USA
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20
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Bober B, Saracyn M, Kołodziej M, Kowalski Ł, Deptuła-Krawczyk E, Kapusta W, Kamiński G, Mozenska O, Bil J. Carcinoid Heart Disease: How to Diagnose and Treat in 2020? CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820968101. [PMID: 33192110 PMCID: PMC7597558 DOI: 10.1177/1179546820968101] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 09/25/2020] [Indexed: 01/17/2023]
Abstract
Neuroendocrine tumors (NETs, originally termed “carcinoids”) create a relatively rare group of neoplasms with an approximate incidence rate of 2.5 to 5 cases per 100 000 persons. Roughly 30% to 40% of subjects with NETs develop carcinoid syndrome (CS), and 20% to 50% of subjects with CS are diagnosed with carcinoid heart disease (CaHD). The long-standing exposure to high serum serotonin concentration is one of the crucial factors in CaHD development. White plaque-like deposits on the endocardial surface of heart structures with valve leaflets and subvalvular apparatus thickening (fused and shortened chordae; thickened papillary muscles) are characteristic for CaHD. NT pro-BNP and 5-hydroxyindoleacetic acid are the 2 most useful screening markers. Long-acting somatostatin analogs are the standard of care in symptoms control. They are also the first-line treatment for tumor control in subjects with a metastatic somatostatin receptor avid disease. In cases refractory to somatostatin analogs, several options are available. We can increase a somatostatin analog to off-label doses, add telotristat ethyl or administer peptide receptor radionuclide therapy. Cardiac surgery, which mainly involves valve replacement, is presently the most efficient strategy in subjects with advanced CaHD and can relieve unmanageable symptoms or be partly responsible for better prognosis.
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Affiliation(s)
- Barbara Bober
- Department of Endocrinology and Isotope Therapy, Military Institute of Medicine, Warsaw, Mazowieckie, Poland
| | - Marek Saracyn
- Department of Endocrinology and Isotope Therapy, Military Institute of Medicine, Warsaw, Mazowieckie, Poland
| | - Maciej Kołodziej
- Department of Endocrinology and Isotope Therapy, Military Institute of Medicine, Warsaw, Mazowieckie, Poland
| | - Łukasz Kowalski
- Department of Endocrinology and Isotope Therapy, Military Institute of Medicine, Warsaw, Mazowieckie, Poland
| | - Elżbieta Deptuła-Krawczyk
- Department of Endocrinology and Isotope Therapy, Military Institute of Medicine, Warsaw, Mazowieckie, Poland
| | - Waldemar Kapusta
- Department of Endocrinology and Isotope Therapy, Military Institute of Medicine, Warsaw, Mazowieckie, Poland
| | - Grzegorz Kamiński
- Department of Endocrinology and Isotope Therapy, Military Institute of Medicine, Warsaw, Mazowieckie, Poland
| | - Olga Mozenska
- Department of Internal Medicine, Hypertension and Vascular Diseases, Warsaw Medical University, Warsaw, Poland
| | - Jacek Bil
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Warsaw, Poland
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21
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Yong MS, Kong G, Ludhani P, Michael M, Morgan J, Hofman MS, Hicks RJ, Larobina M. Early Outcomes of Surgery for Carcinoid Heart Disease. Heart Lung Circ 2020; 29:742-747. [DOI: 10.1016/j.hlc.2019.05.183] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 05/23/2019] [Indexed: 10/26/2022]
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Sunjic I, Shin D, Sunjic KM, Popat JV, Tran T, Chae SH, Caldeira CC, Strosberg JR, Sayad D. Incidence of Atrioventricular Block After Valve Replacement in Carcinoid Heart Disease. Cardiol Res 2020; 11:56-60. [PMID: 32095197 PMCID: PMC7011921 DOI: 10.14740/cr986] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 11/15/2019] [Indexed: 11/11/2022] Open
Abstract
Background Carcinoid heart disease (CaHD) is a rare condition that has a high impact on the morbidity and mortality of its patients. Once heart failure symptoms develop in the patient with CaHD, cardiac valve surgery is often the only effective treatment. Although atrioventricular block (AVB) is a known postoperative complication of the valve surgery, the incidence of AVB in this population has not been well described. Methods Comprehensive records were collected retrospectively on consecutive patients with CaHD who underwent a valve surgery at a tertiary medical center from January 2001 to December 2015. We excluded patients with pre-existing permanent pacemaker (PPM). Results Nineteen consecutive patients were included in this study and 18 of them underwent at least dual valve (tricuspid and pulmonary valve) replacement surgery. Our 30-day post-surgical mortality was 0%. During the 6-month observation period following the surgery, 31.5% (n = 6) required PPM implantation due to complete AVB. There was no statistical difference in baseline characteristics and electrocardiographic and echocardiographic parameters between the patients who did or did not require PPM placement. Conclusions Our study revealed that almost one-third of CaHD patients who underwent a valve replacement surgery developed AVB requiring PPM implantation. Due to high incidence of PPM requirement, we believe that prophylactic placement of an epicardial lead during the valve surgery can be helpful in these patients to reduce serious complication from placement of pacemaker lead on a later date through a prosthetic valve.
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Affiliation(s)
- Igor Sunjic
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, FL 33606, USA.,These authors contributed equally to this work
| | - Doosup Shin
- Division of Cardiovascular Medicine, University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA.,These authors contributed equally to this work
| | - Katlynd M Sunjic
- Department of Pharmacotherapeutics and Clinical Research, University of South Florida College of Pharmacy, Tampa, FL 33606, USA
| | - Jesal V Popat
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, FL 33606, USA
| | - Thanh Tran
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, FL 33606, USA
| | - Sanders H Chae
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, FL 33606, USA
| | - Christiano C Caldeira
- Division of Cardiothoracic Surgery and Cardiology, Tampa General Hospital, Tampa, FL 33606, USA
| | - Jonathan R Strosberg
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL 33612, USA
| | - Dany Sayad
- Division of Cardiovascular Sciences, University of South Florida Morsani College of Medicine, Tampa, FL 33606, USA
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23
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Steeds RP, Sagar V, Shetty S, Oelofse T, Singh H, Ahmad R, Bradley E, Moore R, Vickrage S, Smith S, Yim I, Elhassan YS, Venkataraman H, Ayuk J, Rooney S, Shah T. Multidisciplinary team management of carcinoid heart disease. Endocr Connect 2019; 8:R184-R199. [PMID: 31751305 PMCID: PMC6933832 DOI: 10.1530/ec-19-0413] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 11/11/2019] [Indexed: 11/22/2022]
Abstract
Carcinoid heart disease (CHD) is a consequence of valvular fibrosis triggered by vasoactive substances released from neuroendocrine tumours, classically in those with metastatic disease and resulting in tricuspid and pulmonary valve failure. CHD affects one in five patients who have carcinoid syndrome (CS). Valve leaflets become thickened, retracted and immobile, resulting most often in regurgitation that causes right ventricular dilatation and ultimately, right heart failure. The development of CHD heralds a significantly worse prognosis than those patients with CS who do not develop valvular disease. Diagnosis requires a low threshold of suspicion in all patients with CS, since symptoms occur late in the disease process and clinical signs are difficult to elicit. As a result, routine screening is recommended using the biomarker, N-terminal pro-natriuretic peptide, and regular echocardiography is then required for diagnosis and follow-up. There is no direct medical therapy for CHD, but the focus of non-surgical care is to control CS symptoms, reduce tumour load and decrease hormone levels. Valve surgery improves long-term outcome for those with severe disease compared to medical management, although peri-operative mortality remains at between 10 and 20% in experienced centres. Therefore, care needs to be multidisciplinary at all stages, with clear discussion with the patient and between teams to ensure optimum outcome for these often-complex patients.
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Affiliation(s)
- Richard P Steeds
- Department of Cardiology, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Correspondence should be addressed to R P Steeds:
| | - Vandana Sagar
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Shishir Shetty
- Centre for Liver and Gastrointestinal Research, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Tessa Oelofse
- Departments of Anaesthesia and Intensive Care, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Harjot Singh
- Departments of Anaesthesia and Intensive Care, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Raheel Ahmad
- Department of Cardiology, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Elizabeth Bradley
- Therapy Services (Dietetics), University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Rachel Moore
- Departments of Anaesthesia and Intensive Care, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Suzanne Vickrage
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Stacey Smith
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Ivan Yim
- Department of Cardiothoracic Surgery, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Yasir S Elhassan
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
- Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Hema Venkataraman
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - John Ayuk
- Centre for Endocrinology, Diabetes and Metabolism, Birmingham Health Partners, Birmingham, UK
| | - Stephen Rooney
- Department of Cardiothoracic Surgery, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
| | - Tahir Shah
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
- Department of Hepatology and Liver Transplantation, University Hospitals Birmingham (Queen Elizabeth), NHS Hospitals Foundation Trust, Birmingham, UK
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24
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Hassan SA, Palaskas NL, Agha AM, Iliescu C, Lopez-Mattei J, Chen C, Zheng H, Yusuf SW. Carcinoid Heart Disease: a Comprehensive Review. Curr Cardiol Rep 2019; 21:140. [PMID: 31745664 DOI: 10.1007/s11886-019-1207-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Carcinoid heart disease is a rare disorder that is associated with significant morbidity and mortality. In this review of the literature, we will present current concepts in diagnosis and management of carcinoid heart disease. RECENT FINDINGS Recent expert consensus guidelines highlight the role of echocardiography and screening with NT-proBNP for the evaluation of carcinoid heart disease. Advances in medical therapy along with better surgical outcomes highlight the experience and expertise that has been gained in the treatment of carcinoid heart disease. Carcinoid heart disease occurs in patients with neuroendocrine tumors who have carcinoid syndrome. Serotonin appears to play a central role in the development of carcinoid heart disease. Cardiac biomarkers and multimodality imaging can be used to aid in screening and diagnosis. The mainstay of treatment of carcinoid heart disease is surgery.
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Affiliation(s)
- Saamir A Hassan
- Department of Cardiology, Division of Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Nicolas L Palaskas
- Department of Cardiology, Division of Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ali M Agha
- Department of Cardiology, Division of Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Cezar Iliescu
- Department of Cardiology, Division of Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Juan Lopez-Mattei
- Department of Cardiology, Division of Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher Chen
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Henry Zheng
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Syed Wamique Yusuf
- Department of Cardiology, Division of Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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El Gabry M, Shehada SE, Mourad F, Ruhparwar A, Lahner H, Dirkmann D, Thielmann M, Jakob H, Wendt D. Hedinger syndrome: first experience and two-year follow-up in patients with carcinoid heart disease. J Thorac Dis 2019; 11:3234-3240. [PMID: 31559025 DOI: 10.21037/jtd.2019.08.71] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Carcinoid heart disease (CHD) (Hedinger syndrome) is a rare manifestation, it has been described in up to 60% of patients with both neuroendocrine tumors (NETs) and carcinoid syndrome (CS) which, typically inducing right heart-sided abnormalities. Methods Between 07/15 and 10/18, six patients (mean age 63±12 years; 3 females) presented with manifested (NYHA III-IV) Hedinger syndrome's related valvular(s) lesion and were operated at our center. Clinical data, adverse events and patient outcomes were recorded. Results The tricuspid valve was involved in all patients. Tricuspid valve repair was possible in four patients and two needed replacement. In two patients, operation was performed on beating heart without cross-clamping. Concomitant pulmonary valve replacement in two patients and aortic valve replacement in another two patients. A mean cross-clamp time of 61±50 minutes was observed. One patient with severely impaired right ventricular function needed ECMO support, and died 3 days later due to neuroendocrine enzyme storm. At 13 months, one patient developed severe tricuspid stenosis and underwent re-operation with replacement. Another patient died 18 months after surgery related to the underlying tumour. At mean of 30 months follow-up, four patients were alive and asymptotic. Conclusions Hedinger syndrome is a challenging entity in cardiac surgery characterized by aggressive valve lesions combined with metastatic neuroendocrine neoplasia affecting the systemic circulation. We advise a multidisciplinary collaboration to early diagnose cardiac involvement to offer an early and proper treatment regime.
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Affiliation(s)
- Mohamed El Gabry
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre Essen, University Hospitals Duisburg-Essen, Essen, Germany
| | - Sharaf-Eldin Shehada
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre Essen, University Hospitals Duisburg-Essen, Essen, Germany
| | - Fanar Mourad
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre Essen, University Hospitals Duisburg-Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre Essen, University Hospitals Duisburg-Essen, Essen, Germany
| | - Harald Lahner
- Department of Endocrinology and Metabolism, University Hospitals Duisburg-Essen, Essen, Germany
| | - Daniel Dirkmann
- Department for Anaesthesiology and Intensive Care Medicine, University Hospitals Duisburg-Essen, Essen, Germany
| | - Matthias Thielmann
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre Essen, University Hospitals Duisburg-Essen, Essen, Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre Essen, University Hospitals Duisburg-Essen, Essen, Germany
| | - Daniel Wendt
- Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre Essen, University Hospitals Duisburg-Essen, Essen, Germany
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Agha AM, Lopez-Mattei J, Donisan T, Balanescu D, Iliescu CA, Banchs J, Kim PY, Palaskas NL, Yusuf S, Gladish G, Hassan S. Multimodality imaging in carcinoid heart disease. Open Heart 2019; 6:e001060. [PMID: 31245014 PMCID: PMC6560671 DOI: 10.1136/openhrt-2019-001060] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 04/08/2019] [Accepted: 04/14/2019] [Indexed: 01/05/2023] Open
Abstract
Neuroendocrine neoplasms arise from the gastrointestinal tract and can lead to carcinoid syndrome. Carcinoid heart disease affects more than half of these patients and is the initial presentation of carcinoid syndrome in up to 20 % of patients. Carcinoid heart disease typically leads to valve dysfunction, but in rare instances, carcinoid tumours can also metastasise to the endocardium and myocardium. Cardiovascular imaging plays an integral role in the diagnosis and prognosis of carcinoid heart disease. The use of multimodality imaging techniques including echocardiography, cardiac MRI, cardiovascular CT and positron emission tomography have allowed for a more comprehensive assessment of carcinoid heart disease. In this review, we discuss the features of carcinoid heart disease observed on multimodality imaging, indications for obtaining imaging studies and their role in carcinoid heart disease management.
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Affiliation(s)
- Ali M Agha
- Department of Cardiology, Division of Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Juan Lopez-Mattei
- Department of Cardiology, Division of Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Diagnostic Radiology, Division of Diagnostic Imaging, he University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Teodora Donisan
- Department of Cardiology, Division of Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Dinu Balanescu
- Department of Cardiology, Division of Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Cezar A Iliescu
- Department of Cardiology, Division of Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jose Banchs
- Department of Cardiology, Division of Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Peter Y Kim
- Department of Cardiology, Division of Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Nicolas L Palaskas
- Department of Cardiology, Division of Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Syed Yusuf
- Department of Cardiology, Division of Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Greg Gladish
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, he University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Saamir Hassan
- Department of Cardiology, Division of Internal Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Mortelmans P, Herregods MC, Rega F, Timmermans P. The path to surgery in carcinoid heart disease: a retrospective study and a multidisciplinary proposal of a new algorithm. Acta Cardiol 2019; 74:207-214. [PMID: 29914291 DOI: 10.1080/00015385.2018.1478242] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Background: Development of carcinoid heart disease (CHD) is the major negative prognostic factor in patients with the carcinoid syndrome. The only effective treatment is valve replacement. However, the selection of candidates and determination of optimal timing remain unclear. Considerable variability in local screening and treatment strategies exist. Methods: In this single-centre study, we retrospectively analysed the diagnostic process and outcome of all CHD patients who underwent valve surgery between 2000 and 2016. We propose a new CHD screening and management algorithm. Results: All patients (n = 15), mean age 64 ± 7, underwent tricuspid valve surgery. In 14 of them (93%) an additional valve was replaced. In only a minority of patients (27%) CHD diagnosis was established by screening. Survival after 1, 3, 12 and 24 months was 93%, 80%, 53% and 33%, respectively. Causes of death included infections and critical illness immediately postoperatively, and tumour progression and right heart failure in the longer term. There was a trend (p = .099) towards better preoperative right ventricular function in the patients who survived more than 12 months postoperatively (TAPSE 20 mm ± 4) compared to those who died between 3 to 12 months after surgery (TAPSE 16 mm ± 1). The former group had a shorter mean interval from diagnosis of the carcinoid syndrome to cardiac diagnosis than the latter (13 vs. 105 months, p = .014). Conclusion: Mortality after valve replacement for CHD remains high. A probably underestimated cause is late referral for cardiac surgery. We propose a systematic, multidisciplinary approach to all carcinoid syndrome patients.
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Affiliation(s)
| | | | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
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Balanescu DV, Donisan T, Lopez-Mattei J, Hassan S, Kim P, Dasari A, Halperin D, Yao J, Kar B, Gregoric I, Balanescu SM, Iliescu C. The 1, 2, 3, 4 of carcinoid heart disease: Comprehensive cardiovascular imaging is the mainstay of complex surgical treatment. Oncol Lett 2019; 17:4126-4132. [PMID: 30944605 PMCID: PMC6444330 DOI: 10.3892/ol.2018.9732] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 10/10/2018] [Indexed: 12/29/2022] Open
Abstract
Carcinoid heart disease (CHD) is a rare complication of neuroendocrine tumors, most commonly involving the tricuspid and pulmonary valves. The mitral and aortic valves can also be affected, albeit rarely, in certain circumstances such as the presence of a patent foramen ovale. Transthoracic echocardiogram is generally considered the key imaging modality, but cardiac magnetic resonance can add valuable information, particularly in the assessment of pulmonary valve function or multivalvular disease. Previously, surgical management of CHD carried high mortality, as a result of less advanced surgical techniques and of late intervention, reserved for cases of severely symptomatic heart failure. Modern approaches are associated with significantly improved survival rates, even in multivalvular, complex cases. Valve replacement can provide survival benefits in patients with CHD, but the optimal timing for the intervention is uncertain, with data suggesting a trend of improved survival with earlier intervention. A comprehensive imaging assessment may contribute to establishing optimal surgical timing. This approach may shift the main driver of mortality from the cardiac involvement to the primary malignancy and lead to improved outcomes. We present a series of imaging findings in CHD patients who have successfully undergone simultaneous surgical replacement with bioprosthetic valves of 1 to 4 heart valves. The surgical decision in these patients was based on a multimodality cardiovascular approach, including transthoracic and transesophageal echocardiography and cardiac magnetic resonance. The patients had uncomplicated postoperative courses, significant symptomatic relief from heart failure symptoms, and there was no cardiovascular mortality. Early recognition of CHD with a multimodality approach may improve outcome, even in complex cases. Bioprosthetic valves are generally preferred in CHD due to decreased need for anticoagulation, despite concern for premature degeneration. A collaboration between the Oncology and Cardiology teams is essential for the long-term management of CHD patients.
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Affiliation(s)
- Dinu Valentin Balanescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Teodora Donisan
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Juan Lopez-Mattei
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Saamir Hassan
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Peter Kim
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Arvind Dasari
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Daniel Halperin
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - James Yao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Biswajit Kar
- Center for Advanced Heart Failure, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Igor Gregoric
- Center for Advanced Heart Failure, The University of Texas Health Science Center at Houston, Houston, TX 77030, USA
| | - Serban Mihai Balanescu
- Department of Cardiology, Elias Emergency University Hospital, 'Carol Davila' University of Medicine and Pharmacy, Bucharest 011134, Romania
| | - Cezar Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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Mujtaba SS, Clark S. Quadruple Valve Replacement for Carcinoid Heart Disease. Braz J Cardiovasc Surg 2019; 33:398-403. [PMID: 30184038 PMCID: PMC6122765 DOI: 10.21470/1678-9741-2017-0224] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 02/26/2018] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Carcinoid heart disease most frequently involves the tricuspid or, more rarely, the pulmonary valve and presents with right heart failure as 5-HT is metabolized by the lung. Left-sided valve involvement is quite rare. We describe our experience of 3 patients presenting with heart failure secondary to carcinoid heart disease affecting all four cardiac valves. There are only four previous isolated case reports in the literature. METHODS All three patients underwent quadruple valve replacement during a single operation. Right ventricular outflow tract reconstruction with a pericardial patch was performed in all patients. For 24 hours prior to surgery, all patients received intravenous octreotide, which continued in intensive care for at least 24 hours. RESULTS Mean cross-clamp and bypass times were 175 (range 164-197 minutes) and 210 (range 195-229 minutes) minutes, respectively. Mean intensive treatment unit (ITU) and inpatient stays were 2.3 (range 2-3 days) and 12 (range 9-16 days) days, respectively. One patient was reopened for bleeding 4 hours postoperatively from a ventricular pacing wire site. None required a permanent pacemaker postoperatively. There were no other complications in any patient. The quality of life was excellent at 6-16 months clinic follow-up as they were in NYHA 1. Postoperative echocardiography showed no paravalvular leaks and well-functioning prostheses in all cases. CONCLUSION Surgery to replace all four valves is feasible with excellent medium-term survival and a very low rate of complications. Patients with carcinoid heart disease should always be considered for surgery irrespective of the extent of valvular involvement.
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Affiliation(s)
- Syed Saleem Mujtaba
- Freeman Hospital Newcastle, United Kingdom of Great Britain and Northern Ireland
| | - Stephen Clark
- Freeman Hospital Newcastle, United Kingdom of Great Britain and Northern Ireland
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Domínguez-Massa C, Torregrosa-Puerta S, Serrano-Martínez F, Valera-Martínez FJ. Síndrome carcinoide con afectación cardiaca polivalvular. CIRUGIA CARDIOVASCULAR 2018. [DOI: 10.1016/j.circv.2018.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Alsaad AA, Rojas CA. Cardiac CT Angiography in Carcinoid Heart Disease. Radiology 2018; 290:32. [PMID: 30375927 DOI: 10.1148/radiol.2018181966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Ali A Alsaad
- From the Department of Medicine, Division of Cardiology, University of Chicago-NorthShore University HealthSystem, 2680 Ridge Ave, Evanston, IL 60202 (A.A.A.); and Department of Radiology, Mayo Clinic, Jacksonville, Fla (C.A.R.)
| | - Carlos A Rojas
- From the Department of Medicine, Division of Cardiology, University of Chicago-NorthShore University HealthSystem, 2680 Ridge Ave, Evanston, IL 60202 (A.A.A.); and Department of Radiology, Mayo Clinic, Jacksonville, Fla (C.A.R.)
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Ayala AR, Salerno TA. Commentary: Dance with me to the end of love: Serotonin and the carcinoid heart. J Thorac Cardiovasc Surg 2018; 158:108-109. [PMID: 30414769 DOI: 10.1016/j.jtcvs.2018.09.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 09/18/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Alejandro Raul Ayala
- Department of Medicine, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Fla
| | - Tomas A Salerno
- Division of Cardiothoracic Surgery, University of Miami Miller School of Medicine and Jackson Memorial Hospital, Miami, Fla.
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Abstract
Carcinoid heart disease remains a major cause of morbidity and mortality among patients with carcinoid syndrome and metastatic neuroendocrine tumors. Screening of all patients with N-terminal pro-B-type natriuretic peptide and transthoracic echocardiography is critical for early detection, as early symptoms and signs have low sensitivity for the disease. Cardiac surgery, in appropriate cases, is the only definitive therapy for advanced carcinoid heart disease, and it improves patient symptoms and survival. Management of carcinoid heart disease is complex, and multidisciplinary assessment of cardiac status, hormonal syndrome, and tumor burden is critical in guiding optimal timing of surgery.
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Affiliation(s)
- Aimee R Hayes
- Neuroendocrine Tumour Unit, Royal Free Hospital, Pond Street, London NW3 2QG, UK
| | - Joseph Davar
- Carcinoid Heart Disease Clinic, Department of Cardiology, Royal Free Hospital, Pond Street, London NW3 2QG, UK
| | - Martyn E Caplin
- Neuroendocrine Tumour Unit, Royal Free Hospital, Pond Street, London NW3 2QG, UK.
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de Celis Ferrari ACR, Glasberg J, Riechelmann RP. Carcinoid syndrome: update on the pathophysiology and treatment. Clinics (Sao Paulo) 2018; 73:e490s. [PMID: 30133565 PMCID: PMC6096975 DOI: 10.6061/clinics/2018/e490s] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 03/02/2018] [Indexed: 12/15/2022] Open
Abstract
Approximately 30-40% of patients with well-differentiated neuroendocrine tumors present with carcinoid syndrome, which is a paraneoplastic syndrome associated with the secretion of several humoral factors. Carcinoid syndrome significantly and negatively affects patients' quality of life; increases costs compared with the costs of nonfunctioning neuroendocrine tumors; and results in changes in patients' lifestyle, such as diet, work, physical activity and social life. For several decades, patients with neuroendocrine tumors and carcinoid syndrome have been treated with somatostatin analogues as the first-line treatment. While these agents provide significant relief from carcinoid syndrome symptoms, there is inevitable clinical progression, and new therapeutic interventions are needed. More than 40 substances have been identified as being potentially related to carcinoid syndrome; however, their individual contributions in triggering different carcinoid symptoms or complications, such as carcinoid heart disease, remain unclear. These substances include serotonin (5-HT), which appears to be the primary marker associated with the syndrome, as well as histamine, kallikrein, prostaglandins, and tachykinins. Given the complexity involving the origin, diagnosis and management of patients with carcinoid syndrome, we have undertaken a comprehensive review to update information about the pathophysiology, diagnostic tools and treatment sequence of this syndrome, which currently comprises a multidisciplinary approach.
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Affiliation(s)
| | - João Glasberg
- Disciplina de Radiologia e Oncologia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Rachel P Riechelmann
- Disciplina de Radiologia e Oncologia, Instituto do Cancer do Estado de Sao Paulo (ICESP), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Departamento de Oncologia, AC Camargo Cancer Center Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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Maleszewski JJ, Bois MC, Bois JP, Young PM, Stulak JM, Klarich KW. Neoplasia and the Heart. J Am Coll Cardiol 2018; 72:202-227. [DOI: 10.1016/j.jacc.2018.05.026] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/01/2018] [Accepted: 05/03/2018] [Indexed: 12/17/2022]
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Ramesh S, Kudachi S, Basu S. Peptide Receptor Radionuclide Therapy with 177Lu-DOTATATE in Carcinoid Heart Disease: A Contraindication or a Promising Treatment Approach Bettering Chances for Corrective Surgery? J Nucl Med Technol 2018; 46:292-294. [DOI: 10.2967/jnmt.118.210179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 04/17/2018] [Indexed: 11/16/2022] Open
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Sabatini T, Rozzini R, Morandi GB, Meriggi F, Zorzi F. Primary Carcinoid Tumor of the Ovary: Report of an Unusual Case. TUMORI JOURNAL 2018; 86:91-4. [PMID: 10778776 DOI: 10.1177/030089160008600119] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Carcinoid tumors are endocrine malignancies that are often associated with a characteristic syndrome, the malignant carcinoid syndrome, which is most common in patients with small bowel tumors and liver metastases. In the rare instances when the syndrome is present without liver metastases the primary tumor is usually localized to the bronchus or ovary and secretes hormones directly into the systemic circulation. About two thirds of patients with carcinoid syndrome have evidence of carcinoid heart disease. We report on a case of a primary ovarian carcinoid tumor with an unusual clinical presentation.
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Affiliation(s)
- T Sabatini
- Department of Geriatrics, Poliambulanza Hospital, Brescia, Italy.
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Zlate AC, Alexandrescu ST, Grigorie RT, Gramaticu IM, Kraft A, Dumitru R, Tomescu D, Popescu I. THE ROLE OF SURGERY IN A PATIENT WITH CARCINOID SYNDROME, COMPLICATED BY CARCINOID HEART DISEASE. ACTA ENDOCRINOLOGICA-BUCHAREST 2018; 14:117-121. [PMID: 31149245 DOI: 10.4183/aeb.2018.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A 55-year-old female patient was admitted for flushing and abdominal pain in the right upper quadrant. Her past medical history revealed high blood pressure and a recent echocardiography showed thickened appearance of tricuspid valve with coaptation defect and grade II tricuspid regurgitation. Contrast enhanced abdominal CT scan and MRI were subsequently performed and revealed a large macronodular liver mass, as well as other micronodular lesions disseminated in the liver parenchyma. CT guided biopsy from the main liver mass revealed neuroendocrine tumor of unknown origin (probably GI) with Ki-67 of 8%. Surgical exploration was decided. During laparotomy, the primary tumor was found in the proximal ileum and the patient underwent segmental enterectomy. Non-anatomical hepatectomy was also performed to remove the bulk of the tumor burden (more than 90%). Postoperative course was uneventful and the carcinoid syndrome relieved. At present, 15 months postoperatively, the patient is under treatment with somatostatin analogue for its antiproliferative effect, with good clinical, biochemical and tumoral control and stable heart disease. In patients with neuroendocrine liver metastases from unknown primary, surgical exploration could allow detection (and resection) of the primary tumor and surgical debulking of liver metastases to control carcinoid syndrome and carcinoid heart disease.
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Affiliation(s)
- A C Zlate
- Fundeni Clinical Institute, "Dan Setlacec" Centre of General Surgery and Liver Transplantation, Bucharest, Romania
| | - S T Alexandrescu
- Fundeni Clinical Institute, "Dan Setlacec" Centre of General Surgery and Liver Transplantation, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Faculty of Medicine, Bucharest, Romania
| | - R T Grigorie
- Fundeni Clinical Institute, "Dan Setlacec" Centre of General Surgery and Liver Transplantation, Bucharest, Romania
| | - I M Gramaticu
- Fundeni Clinical Institute, Dept. of Oncology, Bucharest, Romania
| | - A Kraft
- "Titu Maiorescu" University, Faculty of Medicine, Bucharest, Romania
| | - R Dumitru
- Fundeni Clinical Institute, Dept. of Radiology, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Faculty of Medicine, Bucharest, Romania
| | - D Tomescu
- Fundeni Clinical Institute, "Dan Tulbure" Centre of Anesthesiology and Intensive Care, Bucharest, Romania.,"Carol Davila" University of Medicine and Pharmacy, Faculty of Medicine, Bucharest, Romania
| | - I Popescu
- Fundeni Clinical Institute, "Dan Setlacec" Centre of General Surgery and Liver Transplantation, Bucharest, Romania.,"Titu Maiorescu" University, Faculty of Medicine, Bucharest, Romania
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Baxi AJ, Chintapalli K, Katkar A, Restrepo CS, Betancourt SL, Sunnapwar A. Multimodality Imaging Findings in Carcinoid Tumors: A Head-to-Toe Spectrum. Radiographics 2017; 37:516-536. [PMID: 28287937 DOI: 10.1148/rg.2017160113] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Carcinoid tumors are a rare biologically heterogeneous group of neuroendocrine tumors with a spectrum ranging from benign indolent to aggressive metastatic tumors. They belong to the category of amine precursor uptake and decarboxylase tumors, or apudomas. The most common sites for primary locations are the gastrointestinal and respiratory tracts; however, any organ can be involved. The clinical presentation depends on location, aggressiveness, production of biologically active amines and peptides, paraneoplastic syndromes, and tendency for metastasis. Their reported age-adjusted incidence has increased in recent years, partly due to improved detection at radiologic imaging and endoscopy. Not a ll neuroendocrine cell tumors are carcinoids. Numerous systems have been proposed regarding their nomenclature and classification. Cross-sectional and functional imaging plays an important role in diagnosis, lesion characterization, and staging. Awareness of nomenclature, classification, common sites of involvement, and imaging presentation are pivotal for making the diagnosis. Knowledge of the diverse clinical, pathologic, and radiologic spectrum of carcinoid tumors involving various organs of the body is important for diagnosis and patient management. ©RSNA, 2017.
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Affiliation(s)
- Ameya Jagdish Baxi
- From the Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MC 7800, San Antonio, TX 78229-3900 (A.J.B., K.C., A.K., C.S.R., A.S.); and Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.L.B.)
| | - Kedar Chintapalli
- From the Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MC 7800, San Antonio, TX 78229-3900 (A.J.B., K.C., A.K., C.S.R., A.S.); and Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.L.B.)
| | - Amol Katkar
- From the Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MC 7800, San Antonio, TX 78229-3900 (A.J.B., K.C., A.K., C.S.R., A.S.); and Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.L.B.)
| | - Carlos S Restrepo
- From the Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MC 7800, San Antonio, TX 78229-3900 (A.J.B., K.C., A.K., C.S.R., A.S.); and Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.L.B.)
| | - Sonia L Betancourt
- From the Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MC 7800, San Antonio, TX 78229-3900 (A.J.B., K.C., A.K., C.S.R., A.S.); and Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.L.B.)
| | - Abhijit Sunnapwar
- From the Department of Radiology, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, MC 7800, San Antonio, TX 78229-3900 (A.J.B., K.C., A.K., C.S.R., A.S.); and Department of Radiology, MD Anderson Cancer Center, Houston, Tex (S.L.B.)
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41
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Diagnosing and Managing Carcinoid Heart Disease in Patients With Neuroendocrine Tumors: An Expert Statement. J Am Coll Cardiol 2017; 69:1288-1304. [PMID: 28279296 DOI: 10.1016/j.jacc.2016.12.030] [Citation(s) in RCA: 147] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 11/08/2016] [Accepted: 12/10/2016] [Indexed: 12/17/2022]
Abstract
Carcinoid heart disease is a frequent occurrence in patients with carcinoid syndrome and is responsible for substantial morbidity and mortality. The pathophysiology of carcinoid heart disease is poorly understood; however, chronic exposure to excessive circulating serotonin is considered one of the most important contributing factors. Despite recognition, international consensus guidelines specifically addressing the diagnosis and management of carcinoid heart disease are lacking. Furthermore, there is considerable variation in multiple aspects of screening and management of the disease. The aim of these guidelines was to provide succinct, practical advice on the diagnosis and management of carcinoid heart disease as well as its surveillance. Recommendations and proposed algorithms for the investigation, screening, and management have been developed based on an evidence-based review of the published data and on the expert opinion of a multidisciplinary consensus panel consisting of neuroendocrine tumor experts, including oncologists, gastroenterologists, and endocrinologists, in conjunction with cardiologists and cardiothoracic surgeons.
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Abstract
The cardiac manifestations of a neuroendocrine tumour are referred to as carcinoid heart disease (CaHD) and are associated with a poor prognosis. Surgical intervention is the only proven therapeutic option and may prolong survival and quality of life. No consensus has been reached internationally with regard to screening for CaHD and the optimal timing for surgery. Although limited evidence is available on this matter, a trend towards early surgery and subsequent reduced mortality has been observed. In this review we provide an overview of the current understanding and propose a protocol to guide cardiologists in the screening for CaHD and the timing of referral to a specialised surgical centre.
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Bertin N, Favretto S, Pelizzo F, Mos L, Pertoldi F, Vriz O. Carcinoid Heart Disease: Starting From Heart Failure. J Investig Med High Impact Case Rep 2017. [PMID: 28634593 PMCID: PMC5468767 DOI: 10.1177/2324709617713511] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Carcinoid syndrome is the constellation of symptoms mediated by humoral factors produced by some carcinoid tumors. It consists primarily of vasomotor symptoms, gastrointestinal hypermotility, hypotension, and bronchospasm, due to the production and release of vasoactive substances. Carcinoid heart disease occurs in more than 50% of patients with carcinoid syndrome; in some cases, it represents the initial manifestation of the disease. We report the case of a 75-year-old woman with a metastatic neuroendocrine tumor admitted to the emergency room for fatigue and heart failure. Transthoracic echocardiography showed severe tricuspid and pulmonic regurgitation suggesting carcinoid heart disease. A hypervascular retroperitoneal mass was found on abdominal computed tomography, which seemed to arise from the mesenteric artery, anteriorly to the abdominal aorta. Unfortunately, our patient was neither a candidate for mass resection nor for cardiac surgery due to advanced metastatic disease and poor clinical condition. Additionally, we performed a systematic literature review of carcinoid heart disease focusing on typical echocardiographic findings.
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Affiliation(s)
| | | | | | - Lucio Mos
- San Antonio Hospital, San Daniele del Friuli, Udine, Italy
| | | | - Olga Vriz
- San Antonio Hospital, San Daniele del Friuli, Udine, Italy
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44
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Hassan SA, Banchs J, Iliescu C, Dasari A, Lopez-Mattei J, Yusuf SW. Carcinoid heart disease. Heart 2017; 103:1488-1495. [DOI: 10.1136/heartjnl-2017-311261] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/18/2017] [Accepted: 04/20/2017] [Indexed: 12/28/2022] Open
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45
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Tadokoro T, Katsuki S, Ito K, Onitsuka K, Nakashima A, Sasaguri T, Miyata K, Yamamoto H, Mohri M. Inoperable Primary Ovarian Carcinoid Led to the Progression of Carcinoid Heart Disease From Right-Sided to Both-Sided Involvement. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003719. [DOI: 10.1161/circheartfailure.116.003719] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Tomonori Tadokoro
- From the Departments of Cardiology (T.T., S.K., K.I., K.O., K.M., H.Y., M.M.), Cardiovascular Surgery (A.N.), and Pathology (T.S.), Japan Community Healthcare Organization Kyushu Hospital, Kitakyushu, Japan
| | - Shunsuke Katsuki
- From the Departments of Cardiology (T.T., S.K., K.I., K.O., K.M., H.Y., M.M.), Cardiovascular Surgery (A.N.), and Pathology (T.S.), Japan Community Healthcare Organization Kyushu Hospital, Kitakyushu, Japan
| | - Koji Ito
- From the Departments of Cardiology (T.T., S.K., K.I., K.O., K.M., H.Y., M.M.), Cardiovascular Surgery (A.N.), and Pathology (T.S.), Japan Community Healthcare Organization Kyushu Hospital, Kitakyushu, Japan
| | - Ken Onitsuka
- From the Departments of Cardiology (T.T., S.K., K.I., K.O., K.M., H.Y., M.M.), Cardiovascular Surgery (A.N.), and Pathology (T.S.), Japan Community Healthcare Organization Kyushu Hospital, Kitakyushu, Japan
| | - Atsuhiro Nakashima
- From the Departments of Cardiology (T.T., S.K., K.I., K.O., K.M., H.Y., M.M.), Cardiovascular Surgery (A.N.), and Pathology (T.S.), Japan Community Healthcare Organization Kyushu Hospital, Kitakyushu, Japan
| | - Takakazu Sasaguri
- From the Departments of Cardiology (T.T., S.K., K.I., K.O., K.M., H.Y., M.M.), Cardiovascular Surgery (A.N.), and Pathology (T.S.), Japan Community Healthcare Organization Kyushu Hospital, Kitakyushu, Japan
| | - Kenji Miyata
- From the Departments of Cardiology (T.T., S.K., K.I., K.O., K.M., H.Y., M.M.), Cardiovascular Surgery (A.N.), and Pathology (T.S.), Japan Community Healthcare Organization Kyushu Hospital, Kitakyushu, Japan
| | - Hideo Yamamoto
- From the Departments of Cardiology (T.T., S.K., K.I., K.O., K.M., H.Y., M.M.), Cardiovascular Surgery (A.N.), and Pathology (T.S.), Japan Community Healthcare Organization Kyushu Hospital, Kitakyushu, Japan
| | - Masahiro Mohri
- From the Departments of Cardiology (T.T., S.K., K.I., K.O., K.M., H.Y., M.M.), Cardiovascular Surgery (A.N.), and Pathology (T.S.), Japan Community Healthcare Organization Kyushu Hospital, Kitakyushu, Japan
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46
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Bonou M, Kapelios CJ, Kaltsas G, Perreas K, Toutouzas K, Barbetseas J. Cardiac Surgery for Carcinoid Heart Disease: A Weapon Not to Be Misused. Cardiology 2016; 136:243-251. [PMID: 27832643 DOI: 10.1159/000450938] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Accepted: 09/20/2016] [Indexed: 11/19/2022]
Abstract
Carcinoid heart disease (CHD) complicates approximately 25% of patients with a carcinoid tumor and carcinoid syndrome and leads to heart valve degeneration with mixed-stenotic and regurgitation pathology and consequent heart failure (HF) leading to significant morbidity and mortality. Cardiac surgery in symptomatic, severe CHD leads to significantly better functional capacity and prolonged survival when compared to medical treatment alone. Recent studies have shown improvement in postoperative outcomes of patients undergoing surgery for CHD over the last decades. The trend for early diagnosis and application of surgery prior to the manifestation of HF symptoms, which tended to develop during the previous years, does not seem justifiable based on the findings of recent studies. Therefore, the optimal timing of intervention in CHD and the type of valve that should preferably be used remain issues of controversy. This review comprehensively examines the existing literature on the treatment options for patients with CHD, with a special focus on short- and long-term survival after cardiac surgery, and discusses the selection of the exact patient profile and intervention timing that are more likely to optimize the benefit-to-risk ratio for surgical intervention.
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Affiliation(s)
- Maria Bonou
- Department of Cardiology, Laiko General Hospital, Athens, Greece
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47
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Mota JM, Sousa LG, Riechelmann RP. Complications from carcinoid syndrome: review of the current evidence. Ecancermedicalscience 2016; 10:662. [PMID: 27594907 PMCID: PMC4990058 DOI: 10.3332/ecancer.2016.662] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Indexed: 12/24/2022] Open
Abstract
Patients with well-differentiated neuroendocrine tumours may develop carcinoid syndrome (CS), which is characterised by flushing, abdominal cramps, diarrhoea, and bronchospasms. In this scenario, long-term secretion of vasoactive substances—serotonin, tachynins, and others, may induce fibrogenic responses in local or distant tissues, leading to complications such as carcinoid heart disease (CHD), mesenteric and/or retroperitoneal fibrosis. Rare cases of lung/pleural fibrosis and scleroderma have also been described. Despite it not being well described yet, current evidence suggests the pathogenesis of such fibrogenic complications relies on signalling through 5-HT2B and TGF-β1. Medical management is still very limited and lacks prospective and randomised studies for definitive recommendations. Surgical procedures remain the best definitive treatment option for CHD and abdominal fibrosis. Recently, cognitive impairment has also been described as a potential consequence of CS. This review critically discusses the literature concerning the epidemiology, pathogenesis, clinical features, diagnosis, and treatment options for CS-related long-term complications.
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Affiliation(s)
- José Mauricio Mota
- Instituto do Câncer do Estado de São Paulo, University of São Paulo, 01246-000 Brazil
| | - Luana Guimarães Sousa
- Instituto do Câncer do Estado de São Paulo, University of São Paulo, 01246-000 Brazil
| | - Rachel P Riechelmann
- Instituto do Câncer do Estado de São Paulo, University of São Paulo, 01246-000 Brazil
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48
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Early and Late Outcomes of Surgical Treatment in Carcinoid Heart Disease. J Am Coll Cardiol 2016; 66:2189-2196. [PMID: 26564596 DOI: 10.1016/j.jacc.2015.09.014] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Revised: 07/24/2015] [Accepted: 09/02/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Symptoms and survival of patients with carcinoid syndrome have improved, but development of carcinoid heart disease (CaHD) continues to decrease survival. OBJECTIVES This study aimed to analyze patient outcomes after valve surgery for CaHD during a 27-year period at 1 institution to determine early and late outcomes and opportunities for improved patient care. METHODS We retrospectively studied the short-term and long-term outcomes of all consecutive patients with CaHD who underwent valve replacement at our institution between 1985 and 2012. RESULTS The records of 195 patients with CaHD were analyzed. Pre-operative New York Heart Association class was III or IV in 125 of 178 patients (70%). All had tricuspid valve replacement (159 bioprostheses, 36 mechanical), and 157 underwent a pulmonary valve operation. Other concomitant operations included mitral valve procedure (11%), aortic valve procedure (9%), patent foramen ovale or atrial septal defect closure (23%), cardiac metastasectomies or biopsy (4%), and simultaneous coronary artery bypass (11%). There were 20 perioperative deaths (10%); after 2000, perioperative mortality was 6%. Survival rates (95% confidence intervals) at 1, 5, and 10 years were 69% (63% to 76%), 35% (28% to 43%), and 24% (18% to 32%), respectively. Overall mortality was associated with older age, cytotoxic chemotherapy, and tobacco use; 75% of survivors had symptomatic improvement at follow-up. Presymptomatic valve operation was not associated with late survival benefit. CONCLUSIONS Operative mortality associated with valve replacement surgery for CaHD has decreased. Symptomatic and survival benefit is noted in most patients when CaHD is managed by an experienced multidisciplinary team.
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Abstract
Hedinger syndrome refers to carcinoid valvular heart disease. The disease is believed to be triggered by vasoactive substances that result in valvular fibrosis. It classically occurs in patients with metastatic carcinoid and preferentially involves the right sided cardiac valves. Affected valves become thickened and retracted, exhibiting regurgitation and sometimes, stenosis. Echocardiography is recommended in patients with carcinoid syndrome and a follow up study is advisable in those who develop a murmur or other symptoms or signs of valvular heart disease. For appropriately selected patients, valve replacement surgery appears to improve outcomes.
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Affiliation(s)
- Sushil A Luis
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
| | - Patricia A Pellikka
- Division of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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50
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Laule M, Pschowski R, Pape UF, Pavel M, Stangl V, Baumann G, Wiedenmann B, Stangl K. Staged Catheter-Based Valve Treatment of Severe Carcinoid Heart Disease. Neuroendocrinology 2016; 103:259-62. [PMID: 26138598 DOI: 10.1159/000437167] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Accepted: 06/22/2015] [Indexed: 11/19/2022]
Abstract
PURPOSE Carcinoid heart disease (CHD) with severe valve destruction represents the major cause of high morbidity and mortality in patients with carcinoid syndrome. In this paper, we present a novel interventional treatment approach and report the first clinical result achieved in a patient with extensive CHD. METHODS AND RESULTS A woman with an ileal neuroendocrine tumour (G2, Ki67: 5%) presented with severe CHD (NYHA IV) affecting both the pulmonary and the tricuspid valve. First, a balloon-expandable 23-mm Edwards SAPIEN™ was successfully implanted percutaneously into the pulmonary valve. Since no catheter-based techniques were available for the replacement of the native tricuspid valve, we implanted an Edwards SAPIEN 26-mm valve into the vena cava inferior between the right atrium and the ostium of the hepatic veins to reduce abdominal congestion. The implantation was technically successful and completely prevented regurgitation into the vena cava inferior and abdominal veins. After this procedure, the patient's clinical condition improved significantly, and she achieved near-normal exercise tolerance (VO2 max: 24.4 ml O2/kg/min, NYHA II). CONCLUSION We demonstrated that percutaneous valve implantation may offer a novel, minimally invasive option in high-risk patients with severe CHD.
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Affiliation(s)
- Michael Laule
- Department of Cardiology and Angiology, Campus Mitte, Charitx00E9; - University Medicine Berlin, Berlin, Germany
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