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Monlezun DJ, Badalamenti A, Javaid A, Marmagkiolis K, Honan K, Kim JW, Patel R, Akhanti B, Halperin D, Dasari A, Koutroumpakis E, Kim P, Lopez-Mattei J, Yusuf SW, Cilingiroglu M, Mamas MA, Gregoric I, Yao J, Hassan S, Iliescu C. Artificial intelligence-augmented analysis of contemporary procedural, mortality, and cost trends in carcinoid heart disease in a large national cohort with a focus on the "forgotten pulmonic valve". Front Cardiovasc Med 2023; 9:1071138. [PMID: 36843627 PMCID: PMC9945326 DOI: 10.3389/fcvm.2022.1071138] [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: 10/15/2022] [Accepted: 12/30/2022] [Indexed: 02/11/2023] Open
Abstract
Background Carcinoid heart disease is increasingly recognized and challenging to manage due to limited outcomes data. This is the largest known cohort study of valvular pathology, treatment (including pulmonary and tricuspid valve replacements [PVR and TVR]), dispairties, mortality, and cost in patients with malignant carcinoid tumor (MCT). Methods Machine learning-augmented propensity score-adjusted multivariable regression was conducted for clincal outcomes in the 2016-2018 U.S. National Inpatient Sample (NIS). Regression models were weighted by the complex survey design and adjusted for known confounders and the likelihood of undergoing valvular procedures. Results Among 101,521,656 hospitalizations, 55,910 (0.06%) had MCT. Patients with MCT vs. those without had significantly higher inpatient mortality (2.93 vs. 2.04%, p = 0.002), longer mean length of stay (12.20 vs. 4.62, p < 0.001), and increased mean total cost of stay ($70,252.18 vs. 51,092.01, p < 0.001). There was a step-wise increased rate of TVR and PVR with each subsequent year, with significantly more TV (0.16% vs. 0.01, p < 0.001) and PV (0.03 vs. 0.00, p = 0.040) diagnosed with vs. without MCT for 2016, with comparable trends in 2017 and 2018. There were no significant procedural disparities among patients with MCT for sex, race, income, urban density, or geographic region, except in 2017, when the highest prevalence of PV procedures were performed in the Western North at 50.00% (p = 0.034). In machine learning and propensity score augmented multivariable regression, MCT did not significantly increase the likelihood of TVR or PVR. In sub-group analysis restricted to MCT, neither TVR nor PVR significantly increased mortality, though it did increase cost (respectively, $141,082.30, p = 0.015; $355,356.40, p = 0.012). Conclusion This analysis reflects a favorable trend in recognizing the need for TVR and PVR in patients with MCT, with associated increased cost but not mortality. Our study also suggests that pulmonic valve pathology is increasingly recognized in MCT as reflected by the upward trend in PVRs. Further research and updated societal guidelines may need to focus on the "forgotten pulmonic valve" to improve outcomes and disparities in this understudied patient population.
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Affiliation(s)
- Dominique J. Monlezun
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States,Center for Artificial Intelligence and Health Equities, Global System Analytics and Structures (GSAS), New Orleans, LA, United States,*Correspondence: Dominique J. Monlezun ✉
| | - Andrew Badalamenti
- Division of Cardiovascular Medicine, The University of Texas Health Sciences Center at Houston, Houston, TX, United States
| | - Awad Javaid
- Division of Cardiovascular Medicine, Kirk Kerkorian School of Medicine at the University of Nevada-Las Vegas, Las Vegas, NV, United States
| | - Kostas Marmagkiolis
- Division of Cardiovascular Disease, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Kevin Honan
- Division of Cardiovascular Medicine, The University of Texas Health Sciences Center at Houston, Houston, TX, United States
| | - Jin Wan Kim
- Division of Cardiovascular Medicine, The University of Texas Health Sciences Center at Houston, Houston, TX, United States
| | - Rishi Patel
- Division of Cardiovascular Medicine, The University of Texas Health Sciences Center at Houston, Houston, TX, United States
| | - Bindu Akhanti
- Division of Cardiovascular Medicine, The University of Texas Health Sciences Center at Houston, Houston, TX, United States
| | - Dan Halperin
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Arvind Dasari
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Efstratios Koutroumpakis
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Peter Kim
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Juan Lopez-Mattei
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Syed Wamique Yusuf
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Mehmet Cilingiroglu
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Stoke-on-Trent, United Kingdom
| | - Igor Gregoric
- Division of Cardiovascular Medicine, The University of Texas Health Sciences Center at Houston, Houston, TX, United States
| | - James Yao
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Saamir Hassan
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Cezar Iliescu
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
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Stougiannos P, Michas G, Evdoridis C, Arapantoni-Dadioti P, Tolios P, Kaplanis I, Trikas A. Carcinoid heart disease in an elderly female patient: the value of transthoracic echocardiography. Hellenic J Cardiol 2017; 58:65-68. [PMID: 28163144 DOI: 10.1016/j.hjc.2017.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 07/06/2016] [Indexed: 10/20/2022] Open
Affiliation(s)
- Pavlos Stougiannos
- Department of Cardiology, "Elpis" General Hospital of Athens, Athens, Greece
| | - George Michas
- Department of Cardiology, "Elpis" General Hospital of Athens, Athens, Greece
| | | | | | - Panagiotis Tolios
- Department of Cardiology, "Elpis" General Hospital of Athens, Athens, Greece
| | - Ioannis Kaplanis
- Department of Cardiology, "Elpis" General Hospital of Athens, Athens, Greece
| | - Athanasios Trikas
- Department of Cardiology, "Elpis" General Hospital of Athens, Athens, Greece.
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Santos AR, Stuart B, Cotrim C, Almeida AR, Fazendas P, Lopes L, Cruz I, Pereira H. [Carcinoid heart - case report]. Rev Port Cardiol 2012; 31:661-5. [PMID: 22981441 DOI: 10.1016/j.repc.2012.01.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 01/24/2012] [Accepted: 01/26/2012] [Indexed: 11/29/2022] Open
Abstract
We describe the case of a 76-year-old woman, diagnosed with a neuroendocrine tumor of the cecum in 2004, with liver metastases and carcinoid syndrome since September 2010. The patient had been treated intermittently with chemotherapy cycles, and remained symptomatic, with worsening secondary lesions. In June 2011 she began to present signs and symptoms of right heart failure and was hospitalized in September 2011. Transthoracic two- and three-dimensional echocardiography revealed enlarged right atrium and ventricle and thickened and fixed tricuspid and pulmonary valve leaflets, causing severe tricuspid regurgitation and mild pulmonary regurgitation and stenosis, suggestive of carcinoid heart disease. The authors discuss the clinical importance of transthoracic echocardiography, and the more recent three-dimensional echocardiography, as the diagnostic exam of choice in these cases, as it is especially suitable for assessing the valves and subvalvular apparatus.
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Affiliation(s)
- Ana Rita Santos
- Serviço de Cardiologia, Hospital do Espírito Santo, EPE, Évora, Portugal.
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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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Imaging of carcinoid tumors: spectrum of findings with pathologic and clinical correlation. J Comput Assist Tomogr 2011; 35:72-80. [PMID: 21245692 DOI: 10.1097/rct.0b013e3181fd2044] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Carcinoid tumors are primary malignant neoplasms that arise from neuroendocrine cells. These cells are located throughout the body, resulting in many possible locations for the development of carcinoid tumor. The most common primary location is the gastrointestinal tract, followed by respiratory and thymic carcinoids. The presentations of these tumors are variable depending on their location, aggressiveness, production of functional peptides, and tendency to invade or metastasize. Carcinoid tumors can be imaged by various modalities including gastrointestinal studies, ultrasound, computed tomography, and magnetic resonance imaging as well as nuclear medicine studies (radioactive octreotide). In this review, we illustrate the spectrum of imaging features of carcinoid tumors in various locations of the human body.
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Gustafsson BI, Hauso O, Drozdov I, Kidd M, Modlin IM. Carcinoid heart disease. Int J Cardiol 2008; 129:318-24. [PMID: 18571250 DOI: 10.1016/j.ijcard.2008.02.019] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2007] [Accepted: 02/09/2008] [Indexed: 11/16/2022]
Abstract
The carcinoid syndrome is usually evident when enterochromaffin (EC) cell-derived neuroendocrine tumors (carcinoids) metastasize to the liver. In addition to carcinoid symptomatology, about 40% of patients exhibit carcinoid heart disease (CHD) with fibrotic endocardial plaques and associated heart valve dysfunction. The mechanism behind CHD development is not fully understood, but serotonin (5-HT) is considered to be a major initiator of the fibrotic process. Most patients present with right-sided heart valve dysfunction since pulmonary and tricuspid valves lesions are the most common (>95%) cardiac pathology. Left-sided valvular involvement, and angina associated with coronary vasospasm occur in ~10% of subjects with CHD. Pathognomonic echocardiograpic features include immobility of valve leaflets and thickening and retraction of the cusps most commonly resulting in tricuspid valve regurgitation and pulmonary stenosis. Therapeutic options include cardioactive pharmacotherapy for heart failure and, in selected individuals, cardiac valve replacement. Previously valve replacement was reserved for advanced disease due to a perioperative mortality of >20% however in the last decade, technical advances as well as an earlier diagnosis have decreased surgical mortality to <10% and valve replacements are undertaken more frequently. A recent analysis of 200 cases demonstrated an increase in median survival from 1.5 years to 4.4 years in the last two decades. Although the improved prognosis might also reflect the increased use of surgical cytoreduction, hepatic metastatic ablative therapies and somatostatin analogs a robust correlation between diminution of circulating tumor products and an increased long-term survival in CHD has not been rigorously demonstrated.
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Affiliation(s)
- B I Gustafsson
- Department of Gastroenterological Surgery, Yale University School of Medicine New Haven, CT06520-8062, USA
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