Carcinoid heart disease with right to left shunt across a patent foramen ovale: a case report and review of literature

Orthodeoxia Platypnea Syndrome in the Setting of Cholangiocarcinoma: A Case Report

Platypnea-orthodeoxia syndrome is a rare cause of positional hypoxemia and dyspnea. We present the case of a 54-year-old man with right-to-left shunting through a patent foramen ovale in the setting of metastatic cholangiocarcinoma resulting in platypnea-orthodeoxia syndrome. The shunt was originally not visualized on cardiac magnetic resonance imaging but later detected with transesophageal echocardiography. This case highlights the importance of complimentary multimodality cardiac imaging in the diagnosis of both common and uncommon disorders.

Patent foramen ovale in carcinoid heart disease: The potential role for and risks of percutaneous closure prior to cardiothoracic surgery

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.

Carcinoid heart disease involving the left heart: a case report and biomarker analysis

Herein, we report the case of a 67‐year‐old woman who was admitted to our hospital because of dyspnoea and oedema of the lower extremities. Transthoracic echocardiography revealed severe tricuspid and mitral regurgitation, and the leaflets of the tricuspid valve were found to be rigid and almost immobile. The plasma concentrations of serotonin and chromogranin A were elevated, and hence, suspicion for carcinoid heart disease was raised. In addition to the diagnostic workup and medical and surgical treatment, we analysed levels of novel cardiovascular biomarkers throughout the entire follow‐up by means of enzyme‐linked immunosorbent assay. A dopa positron emission tomography (DOPA‐PET) was conducted and showed a neoplasm in the terminal ileum. Tricuspid valve replacement, mitral valve repair, and a closure of the patent foramen ovale (PFO) were conducted. Two months later, hemicolectomy and liver segment resection were performed. The tumour was resected, and the diagnosis of a neuroendocrine tumour (NET) was confirmed. Throughout the follow‐up, we observed a decrease in the plasma levels of novel biomarkers [e.g. interleukin‐8 (IL‐8), soluble suppression of tumorigenicity‐2 (sST2), and heart‐type fatty acid‐binding protein (H‐FABP)] over the follow‐up period. In our case, carcinoid heart disease resulted in a severe tricuspid regurgitation as commonly seen in these patients. Moreover, a pre‐existent mitral regurgitation was likely aggravated by fibrotic remodelling, because a PFO has led to a right‐to‐left shunt and might have caused left heart involvement. As IL‐8 was associated with adverse outcomes in patients with NETs, and sST2 and H‐FABP were associated with adverse outcomes in patients with heart failure previously, these biomarkers could aid in the risk stratification of patients with NET.

4-Valve Heart Disease and Right Heart Failure

Carcinoid heart disease is a rare form of heart disease due to secretion of vasoactive compounds, including serotonin, from gastrointestinal tumors. This E-challenge examines the case of a patient with advanced carcinoid heart disease who presented to the operating room (OR) for a tricuspid valve replacement. Once the patient was in the OR, intraoperative transesophageal echocardiography was used to discover a patent foramen ovale and involvement of all 4 valves with regurgitant lesions. The patient underwent tricuspid valve replacement, pulmonic valve replacement, right ventricular outflow tract reconstruction, and patent foramen closure in the OR and experienced subsequent fulminant right heart failure. Mechanical circulatory support was required to separate the patient from cardiopulmonary bypass, which was first attempted with an intra-aortic balloon pump and subsequently achieved with implantation of a right ventricular assist device. Multiple reports of acute right heart failure are available in the literature; however, this case helps illustrate several important considerations for the anesthesiologist. The effects of chronic circulating vasoactive compounds on the heart valves are well documented; however, it is likely that advanced carcinoid heart disease also will trigger pre-existing myocardial dysfunction, which may be underappreciated. Identifying patients who are at high risk for intraoperative right heart failure and considering what constitutes an adequate preoperative assessment of right heart function aid in preparing for OR management. In addition, reviewing the potential options for managing these patients when the traditional therapies are inadequate, including mechanical support and extracorporeal circulation, is a useful exercise in preparation. This case also highlights the contributions of intraoperative transesophageal echocardiography in the diagnosis and management of carcinoid heart disease, the need for additional preoperative optimization of these patients, and the management and potential complications of mechanical support.

Noninvasive evaluation of right hemodynamics in carcinoid heart disease: A case report

We report the case of a 67-year-old woman with a carcinoid tumor of midgut origin who developed carcinoid heart disease and died because of bowel perforation. Echocardiography allowed the diagnosis, recognizing the typical abnormalities of tricuspid and pulmonary valve leaflets. The sonographic examination also evidenced peculiar alterations of the right heart hemodynamics: end-diastolic reversal of flow at the level of the pulmonary valve, reduced respiratory excursion without enlargement of the inferior vena cava, and biphasic hepatic venous flow without respiratory variation. Echocardiography allowed both the diagnosis and the accurate assessment of the hemodynamic consequences of the disease. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:355-361, 2017.