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Douglas S, Oelofse T, Shah T, Rooney S, Arif S, Steeds RP. Patent foramen ovale in carcinoid heart disease: The potential role for and risks of percutaneous closure prior to cardiothoracic surgery. J Neuroendocrinol 2023; 35:e13323. [PMID: 37580851 DOI: 10.1111/jne.13323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 06/20/2023] [Accepted: 07/07/2023] [Indexed: 08/16/2023]
Abstract
Neuroendocrine tumours (NETs) are rare but once metastasised, can lead to the release of vasoactive substances into the systemic circulation, and the classical features of carcinoid syndrome (CS) such as flushing and diarrhoea. A consequence of CS is carcinoid heart disease (CHD) which primarily affects the right-sided heart valves and can eventually lead to right heart failure. In this cohort, tricuspid and/or pulmonary valve replacement provides symptomatic relief. A patent foramen ovale (PFO) in patients with CHD can lead to the shunting of oxygen deficient blood to the systemic circulation causing hypoxaemia and reduced exercise tolerance. Additionally, the haemodynamic changes caused by regurgitant right-sided heart valves can increase the patency of a PFO allowing the passage of vasoactive substances to the systemic circulation thereby affecting the left-sided heart valves. We present data on the incidence of PFO in patients referred for surgery at our centre, in which the standard approach is to close the defect at time of cardiothoracic surgery. In addition, we present a series of four cases that highlight how the option of percutaneous PFO closure prior to open valve surgery may reduce haemodynamic instability and open a window of opportunity to enhance preoperative status. Percutaneous PFO closure then acts as a bridge to definitive cardiothoracic surgery, although there are risks in such an approach.
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Affiliation(s)
- Sasha Douglas
- Department of Cardiology, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Tessa Oelofse
- Departments of Anaesthesia and Intensive Care, 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
| | - Stephen Rooney
- Department of Cardiothoracic Surgery, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham, UK
| | - Sayqa Arif
- Department of Cardiology, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham, UK
| | - 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
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Chowdhury MA, Taleb M, Kakroo MA, Tinkel J. Carcinoid heart disease with right to left shunt across a patent foramen ovale: a case report and review of literature. Echocardiography 2014; 32:165-9. [PMID: 24976489 DOI: 10.1111/echo.12671] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
Carcinoid tumors are rare, indolent neuroendocrine tumors that are often associated with a syndrome characterized by episodic flushing, secretory diarrhea, bronchospasm, and hypotension-the carcinoid syndrome. Cardiac involvement occurs in one-half to two-thirds of patients with carcinoid syndrome and is associated with a worse clinical outcome. Carcinoid heart disease is characterized by endocardial plaque-like deposits found predominantly on right-sided heart valves, leading to the combination of valvular stenosis and regurgitation. Left-sided cardiac involvement can also occur in <10% of patients. Somatostatin analogs form the therapeutic cornerstone in the medical management of these patients. Cytotoxic chemotherapy has had only limited success in the treatment of metastatic carcinoid tumors. Hepatic resection or palliative cytoreduction may be of benefit in patients with limited hepatic disease. Hepatic artery embolization is usually applied if a patient is not eligible for surgical debulking. The development and progression of carcinoid heart disease are associated with an unfavorable outcome. In those patients having severe cardiac involvement and well-controlled systemic disease, valve replacement surgery has been found to be an effective treatment that can both relieve intractable symptoms and contribute to improved clinical outcomes.
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Hayashi Y, McGaw DJ, Goldstein J. Urgent Transcatheter Closure of Patent Foramen Ovale followed by Elective Right-Sided Valve Surgery for Decompensated Carcinoid Heart Disease. Heart Lung Circ 2008; 17:259-61. [PMID: 17416551 DOI: 10.1016/j.hlc.2007.02.099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2006] [Revised: 02/18/2007] [Accepted: 02/22/2007] [Indexed: 10/23/2022]
Abstract
The presence of a patent foramen ovale (PFO) is associated with morbidity and mortality in patients with carcinoid heart disease (CHD). We report a 66-year-old male patient with tricuspid and pulmonary valve regurgitation secondary to CHD, who developed severe hypoxia due to a right-to-left shunt through a PFO. A 35 mm Amplatzer septal occluder was deployed to reduce the right-to-left shunt as an urgent procedure. Tricuspid and pulmonary valve replacements were electively performed using ON-X mechanical prostheses (31/33 mm and 19 mm, respectively) 70 days after the percutaneous procedure. Transcatheter closure of a PFO prior to definitive right-sided valve surgery can be a useful treatment for CHD patients with acute haemodynamic derangement.
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Affiliation(s)
- Yoshitaka Hayashi
- Cardiothoracic Surgery Unit, Monash Medical Centre, 246 Clayton Road, Clayton, Victoria 3168, Australia
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Affiliation(s)
- Sanjeev Bhattacharyya
- Carcinoid Heart Disease Clinic, Department of Cardiology, Royal Free Hospital, Pond St, London, NW3 2QG, UK
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KIM MICHAELS, KLEIN ANDREWJ, CARROLL JOHND. Transcatheter Closure of Intracardiac Defects in Adults. J Interv Cardiol 2007; 20:524-45. [DOI: 10.1111/j.1540-8183.2007.00304.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
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Chaudhari PR, Abergel J, Warner RR, Zacks J, Love BA, Halperin JL, Adler E. Percutaneous closure of a patent foramen ovale in left-sided carcinoid heart disease. ACTA ACUST UNITED AC 2007; 4:455-9. [PMID: 17653118 DOI: 10.1038/ncpcardio0944] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2006] [Accepted: 03/30/2007] [Indexed: 11/09/2022]
Abstract
BACKGROUND A 51-year-old woman with a 5-year history of metastatic small bowel carcinoid disease developed fatigue and gradually worsening dyspnea on exertion, over 6 months. INVESTIGATIONS Physical examination, transthoracic and transesophageal echocardiography, and aortography. DIAGNOSIS Left-sided carcinoid disease associated with a patent foramen ovale. MANAGEMENT Percutaneous transcatheter closure of the patent foramen ovale.
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Asirdizer M, Tatlisumak E. The role of eustachian valve and patent foramen ovale in sudden death. ACTA ACUST UNITED AC 2006; 13:262-7. [PMID: 16442333 DOI: 10.1016/j.jcfm.2005.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2005] [Revised: 11/11/2005] [Accepted: 11/20/2005] [Indexed: 10/25/2022]
Abstract
Sudden unexpected cardiac death is the leading cause of death in industrialized countries. Patent foramen ovale and eustachian valve are two of cardiac diseases and they may be associated with clinical disorders as embolism, stroke, plathypnea-orthodeoxia syndrome, carcinoid heart disease, atrial flutter and endocarditis. The literature for the roles of patent foramen ovale and eustachian valve in the causes of sudden deaths are reviewed.
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Affiliation(s)
- Mahmut Asirdizer
- Department of Forensic Medicine, Medical Faculty of Celal Bayar University, 45030 Manisa, Turkey.
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Schuchlenz HW, Weihs W, Hackl E, Rehak P. A large Eustachian valve is a confounder of contrast but not of color Doppler transesophageal echocardiography in detecting a right-to-left shunt across a patent foramen ovale. Int J Cardiol 2006; 109:375-80. [PMID: 16023746 DOI: 10.1016/j.ijcard.2005.06.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2004] [Revised: 04/04/2005] [Accepted: 06/17/2005] [Indexed: 01/04/2023]
Abstract
BACKGROUND Transesophageal contrast echocardiography (cTEE) is considered to be the method of choice for diagnosing patent foramen ovale (PFO), but its diagnostic accuracy compared with color Doppler guided TEE in the presence of an Eustachian valve (EV) has not been evaluated. The main aim of this study was to assess the diagnostic accuracy for PFO diagnosis of color Doppler TEE at low pulse repetition frequency. METHODS We ascertained the presence of PFO and EV using cTEE and transthoracic contrast echocardiography (cTTE) in 292 consecutive patients (age 42+/-12 years) with cryptogenic stroke. A diagnosis of PFO was based on the observation of right-to-left shunting of contrast bubbles or by color Doppler with pulse repetition frequency of 20-30 cm/s. An EV with a diameter of >1.5 cm in the bicaval view was considered large. RESULTS Overall 204 patients (70%) had evidence of a right-to-left shunt by either contrast echo method. Shunting was demonstrated more frequently by color Doppler than by cTEE, either spontaneously (133 vs. 92; p=0.01) or during provocative maneuvers (166 vs. 184; p=0.01). The sensitivity of color Doppler was significantly higher than that of cTEE (90% vs. 81%; p=0.01). A large EV was found in 37 patients, 31 (84%) of whom had a PFO. The presence of a large EV did not significantly influence the sensitivity of color Doppler for detecting shunting through a PFO, but the sensitivity of cTTE and cTEE was significantly reduced (from 88% to 42%, p<0.001). CONCLUSIONS Color Doppler TEE is more accurate than traditional cTEE for PFO diagnosis and is not negatively influenced by the presence of an EV, provided that a low pulse repetition frequency is used.
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Guérin P, Lambert V, Godart F, Legendre A, Petit J, Bourlon F, De Geeter B, Petit A, Monrozier B, Rossignol AM, Jimenez M, Crochet D, Choussat A, Rey C, Losay J. Transcatheter Closure of Patent Foramen Ovale in Patients with Platypnea-Orthodeoxia: Results of a Multicentric French Registry. Cardiovasc Intervent Radiol 2005; 28:164-8. [PMID: 15719178 DOI: 10.1007/s00270-004-0035-3] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Dyspnea and the decrease in arterial saturation in the upright position in elderly subjects is described as platypnea-orthodeoxia syndrome (POS). POS is secondary to the occurrence of an atrial right-to-left shunt through a patent foramen ovale (PFO). METHODS This French multicentric study reports on 78 patients (mean age 67 +/- 11.3 years) with POS who had transcatheter closure of the PFO; frequently associated diseases were pneumonectomy (n = 36) and an ascending aortic aneurysm (n = 11). In all patients, the diagnosis was confirmed by transthoracic or/and transesophageal echocardiography. Five different closure devices were used: Amplatz (n = 45), Cardioseal (n = 13), Sideris (n = 11), Das Angel Wings (n = 8) and Starflex (n = 1). Closure was successful in 76 patients (97%). RESULTS Oxygen saturation increased immediately after occlusion from 84.6 +/- 10.7% to 95.1 +/- 6.4% (p < 0.001) and dyspnea improved from grade 2.7 +/- 0.7 to grade 1 +/- 1 (p < 0.001). A small residual shunt was immediately observed in 5 patients (3 with the Cardioseal device, 1 with the Sideris and 1 with the Amplatz) leading to the implantation of a second device in one case (Cardioseal). Two early deaths occurred unrelated to the procedure (one due to sepsis probably related to pneumonectomy, another due to respiratory insufficiency). Other complications were: a small shunt between the aorta and the left atrium, two atrial fibrillations and a left-sided thrombus which disappeared with anticoagulant therapy. At a mean follow-up of 15 +/- 12 months, there were 7 late deaths related to the underlying disease. CONCLUSION Percutaneous occlusion of the foramen ovale is safe and gives excellent results thanks to continuing improvement in available devices. This technique enables some patients in an unstable condition to avoid a surgical closure.
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Affiliation(s)
- P Guérin
- Centre hémodynamique, Hôpital Guillaume et René Laënnec, CHU Nantes, Boulevard Jacques Monod, BP 1005, 440930 Nantes, France.
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Du ZD, Cao QL, Joseph A, Koenig P, Heischmidt M, Waight DJ, Rhodes J, Brorson J, Hijazi ZM. Transcatheter closure of patent foramen ovale in patients with paradoxical embolism: intermediate-term risk of recurrent neurological events. Catheter Cardiovasc Interv 2002; 55:189-94. [PMID: 11835645 DOI: 10.1002/ccd.10067] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Closure of patent foramen ovale (PFO) has been proposed as an alternative to anticoagulation in patients with presumed paradoxical emboli. We report our preliminary intermediate results of patients who underwent transcatheter PFO closure for paradoxical embolism using DAS-Angel Wings occluder or Amplatzer devices. Eighteen patients (8 male/10 female) underwent catheter closure of their PFOs at a median age of 42 years. The complete closure rate was 67% immediately after the procedure and 100% at a mean follow-up interval of 2.2 +/- 1.8 years. The mean fluoroscopy time and procedure time in the Amplatzer group were 8.5 +/- 3.2 min and 65 +/- 21 min, respectively, which were significantly shorter than those of DAS-Angel Wings group (18.9 +/- 4.7 min and 137 +/- 28 min, respectively). There were no recurrent embolic neurological events following device placement in this subset of patients. No complications were encountered either during or after the closure procedure. In conclusion, transcatheter closure of PFO seems to be an effective alternative therapy in the prevention of presumed paradoxical emboli. Further study is needed to identify patients most likely to benefit from this intervention.
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Affiliation(s)
- Zhong-Dong Du
- Section of Pediatric Cardiology, Department of Pediatrics, University of Chicago Children's Hospital, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
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