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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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Brooke A, Porter-Bent S, Hodson J, Ahmad R, Oelofse T, Singh H, Shah T, Ashoub A, Rooney S, Steeds RP. The Role of Transthoracic Echocardiography for Assessment of Mortality in Patients with Carcinoid Heart Disease Undergoing Valve Replacement. Cancers (Basel) 2023; 15:cancers15061875. [PMID: 36980761 PMCID: PMC10046658 DOI: 10.3390/cancers15061875] [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: 02/17/2023] [Revised: 03/14/2023] [Accepted: 03/18/2023] [Indexed: 03/30/2023] Open
Abstract
Patients with carcinoid heart disease (CHD) are referred for valve replacement if they have severe symptomatic disease or evidence of right ventricular (RV) failure and an anticipated survival of at least 12 months. Data are lacking, however, on the role of transthoracic echocardiography in predicting outcomes. We carried out a retrospective, single-centre cohort study of patients with a biopsy-confirmed neuroendocrine tumour (NET) and CHD undergoing valve replacement for severe valve disease and symptoms of right heart failure. The aim was to identify factors associated with postoperative mortality, both within one year of surgery and during long-term follow-up. Of 88 patients with NET, 49 were treated surgically (mean age: 64.4 ± 7.6 years; 55% male), of whom 48 had a bioprosthetic tricuspid valve replacement for severe tricuspid regurgitation; 39 patients had a pulmonary valve replacement. Over a median potential follow-up of 96 months (interquartile range: 56-125), there were 37 deaths, with 30-day and one-year mortality of 14% (n = 7) and 39% (n = 19), respectively. A significant relationship between RV size and one-year mortality was observed, with 57% of those with severe RV dilatation dying within a year of surgery, compared to 33% in those with normal RV size (p = 0.039). This difference remained significant in the time-to-event analysis of long-term survival (p = 0.008). RV size was found to reduce significantly with surgery (p < 0.001). Those with persisting RV dilatation (p = 0.007) or worse RV function (p = 0.001) on postoperative echocardiography had significantly shorter long-term survival. In this single-centre retrospective study of patients undergoing surgery for CHD, increasingly severe RV dilatation on preoperative echocardiography predicted adverse outcomes, yielding a doubling of the one-year mortality rate relative to normal RV size. These data support the possibility that early surgery might deliver greater long-term benefits in this patient cohort.
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Affiliation(s)
- Abigail Brooke
- Department of Cardiology, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham B15 2TH, UK
| | - Sasha Porter-Bent
- Department of Cardiology, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham B15 2TH, UK
- Institute of Cardiovascular Sciences, University of Birmingham, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham B15 2TH, UK
| | - James Hodson
- Institute of Translational Medicine, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham B15 2TH, UK
| | - Raheel Ahmad
- Department of Cardiology, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham B15 2TH, UK
| | - Tessa Oelofse
- Department of Cardiac Anaesthesia and Intensive Care, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham B15 2TH, UK
| | - Harjot Singh
- Department of Cardiac Anaesthesia and Intensive Care, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham B15 2TH, UK
| | - Tahir Shah
- Birmingham Neuroendocrine Tumour Centre, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham B15 2TH, UK
| | - Ahmed Ashoub
- Department of Cardiothoracic Surgery, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham B15 2TH, UK
| | - Stephen Rooney
- Department of Cardiothoracic Surgery, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham B15 2TH, UK
| | - Richard P Steeds
- Department of Cardiology, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham B15 2TH, UK
- Institute of Cardiovascular Sciences, University of Birmingham, University Hospitals Birmingham (Queen Elizabeth) NHS Hospitals Foundation Trust, Birmingham B15 2TH, UK
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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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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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Timmermans P, Rega F, Bogaert J, Herregods MC. Exercise cardiac magnetic resonance imaging with pulmonary artery catheter monitoring in carcinoid heart disease: a shift towards early intervention? ESC Heart Fail 2018; 5:953-955. [PMID: 30080311 PMCID: PMC6165946 DOI: 10.1002/ehf2.12328] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 06/04/2018] [Indexed: 12/03/2022] Open
Abstract
Neuroendocrine tumours are a rare malignancy, which can be complicated by a carcinoid syndrome and, in more rare cases, also valve destruction. The correct timing for surgical repair remains unknown. We report the first‐in‐men exercise cardiac magnetic resonance imaging with pulmonary artery catheter measurements in order to better understand the haemodynamic impact of isolated tricuspid valve insufficiency in a low symptomatic patient. Not pressure but volume overload is the key factor in the development of symptoms, as long as the right ventricular function is intact. Based on our findings, we referred the patient for tricuspid valve replacement. This case, together with the review of all carcinoid heart disease cases in our hospital (a large tertiary cardiology and oncology centre) since 2000, indicates a potential benefit for early intervention in carcinoid heart disease.
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Affiliation(s)
- Philippe Timmermans
- Division of Cardiology, University Hospital Leuven, Herestraat 49, 3000, Leuven, Belgium.,Division of Cardiology, Jessa Hospital Hasselt, Hasselt, Belgium
| | - Filip Rega
- Division of Cardiac Surgery, University Hospital Leuven, Leuven, Belgium
| | - Jan Bogaert
- Division of Radiology, University Hospital Leuven, Leuven, Belgium
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