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Ghukasyan H. Hedinger Syndrome: A Rare Cardiac Manifestation of Carcinoid Syndrome. Cureus 2022; 14:e26528. [PMID: 35795576 PMCID: PMC9250807 DOI: 10.7759/cureus.26528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2022] [Indexed: 11/16/2022] Open
Abstract
Carcinoid syndrome can cause desmoplastic reactions to nearby tissues. When it involves the heart, it causes carcinoid heart disease (CHD) or Hedinger syndrome and usually involves the right-sided heart valves, causing tricuspid insufficiency and pulmonary stenosis (TIPS) and eventually leading to right-sided heart failure. The management of patients with CHD is complex, as both the systemic malignant disease and the heart involvement have to be addressed. Its prompt diagnosis and early treatment is paramount as CHD is associated with increased morbidity and mortality. A 61-year-old Caucasian male with a recently diagnosed metastatic neuroendocrine tumor presented to the heart failure clinic with decompensated heart failure, anasarca, flushing and diarrhea. This case highlights the common clinical features of carcinoid syndrome, its cardiac manifestations and the pathophysiology underlying the manifestations and treatment decisions that involve addressing both systemic and cardiac manifestations.
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Ram P, Penalver JL, Lo KBU, Rangaswami J, Pressman GS. Carcinoid Heart Disease: Review of Current Knowledge. Tex Heart Inst J 2019; 46:21-27. [PMID: 30833833 DOI: 10.14503/thij-17-6562] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Carcinoid heart disease is the collective term for all cardiac manifestations in patients who have carcinoid syndrome. Carcinoid heart disease has a multifactorial pathophysiology, and the right side of the heart is usually involved. Symptoms and signs vary depending upon the affected cardiac components; most typical is right-sided heart failure secondary to diseased tricuspid and pulmonary valves. Despite no single ideal diagnostic test, strong suspicion, coupled with serologic and imaging results, usually enables diagnosis. Advances in imaging, such as speckle-tracking echocardiography and cardiac magnetic resonance, have improved the diagnostic yield. Treatment is challenging, warrants a multidisciplinary approach, and can be medical or surgical depending on the cardiac manifestations. Investigators are exploring the therapeutic use of monoclonal antibodies and new somatostatin analogues. In this review, we cover current knowledge about the pathophysiology, diagnosis, and treatment of carcinoid heart disease.
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Ram P, Penalver JL, Lo KBU, Rangaswami J, Pressman GS. Carcinoid Heart Disease: Review of Current Knowledge. Tex Heart Inst J 2019. [PMID: 30833833 DOI: 10.14503/thij-17-65623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Carcinoid heart disease is the collective term for all cardiac manifestations in patients who have carcinoid syndrome. Carcinoid heart disease has a multifactorial pathophysiology, and the right side of the heart is usually involved. Symptoms and signs vary depending upon the affected cardiac components; most typical is right-sided heart failure secondary to diseased tricuspid and pulmonary valves. Despite no single ideal diagnostic test, strong suspicion, coupled with serologic and imaging results, usually enables diagnosis. Advances in imaging, such as speckle-tracking echocardiography and cardiac magnetic resonance, have improved the diagnostic yield. Treatment is challenging, warrants a multidisciplinary approach, and can be medical or surgical depending on the cardiac manifestations. Investigators are exploring the therapeutic use of monoclonal antibodies and new somatostatin analogues. In this review, we cover current knowledge about the pathophysiology, diagnosis, and treatment of carcinoid heart disease.
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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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Karimi A, Pourafshar N, Fudge JC. Pulmonary and tricuspid valvuloplasty in carcinoid heart disease. Catheter Cardiovasc Interv 2016; 91:E68-E71. [PMID: 28029208 DOI: 10.1002/ccd.26615] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 04/04/2016] [Accepted: 05/08/2016] [Indexed: 11/10/2022]
Abstract
A 26-year-old female with carcinoid heart disease consisting of severe pulmonary and tricuspid valve stenosis was admitted with line associated sepsis. She recovered from sepsis with antibiotics and aggressive fluid resuscitation but became grossly volume overloaded with evidence of tense ascites and lower extremity edema. She developed worsening renal and hepatic function due to congestive nephropathy and hepatopathy, which did not respond to intravenous diuretics, and she was deemed too sick for surgical pulmonary and tricuspid valve replacement. Pulmonary and tricuspid valvuloplasty was performed as a rescue measure to alleviate her congestive symptoms and improve her candidacy for valve replacement. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
- Ashkan Karimi
- Division of Cardiovascular Medicine, University of Florida, Gainesville, Florida
| | - Negiin Pourafshar
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida
| | - James C Fudge
- Division of Pediatric Cardiology, Congenital Heart Center, University of Florida, Gainesville, Florida
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Rasmussen VG, Kanstrup HL, Nielsen-Kudsk JE. Percutaneous balloon valvuloplasty in carcinoid pulmonary valve stenosis. Catheter Cardiovasc Interv 2015; 88:1174-1176. [PMID: 27976548 DOI: 10.1002/ccd.26321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Accepted: 10/09/2015] [Indexed: 11/10/2022]
Abstract
More than half of patients with carcinoid syndrome develop carcinoid valve disease. Both the tricuspid and pulmonary valve are often involved. Symptoms of carcinoid syndrome with flushing, diarrhea, and bronchospasm often precedes cardiac symptoms. We report a case of carcinoid initially presenting with rapid development of right heart failure due to severe pulmonary valve stenosis. In untreated carcinoid, there is a risk of carcinoid crisis with anesthesia and surgery. In local anesthesia, we performed a sub-acute balloon pulmonary valvuloplasty. The procedure was successful without any residual pulmonary valve stenosis and with immediately relief of dyspnea. The final diagnostic workup for the underlying malignancy continued the day after valvuloplasty. © 2015 Wiley Periodicals, Inc.
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Patel C, Mathur M, Escarcega RO, Bove AA. Carcinoid heart disease: current understanding and future directions. Am Heart J 2014; 167:789-95. [PMID: 24890526 DOI: 10.1016/j.ahj.2014.03.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 03/17/2014] [Indexed: 12/11/2022]
Abstract
Carcinoid tumors are rare and aggressive malignancies. A multitude of vasoactive agents are central to the systemic effects of these tumors. The additional burden of cardiac dysfunction heralds a steep decline in quality of life and survival. Unfortunately, by the time carcinoid syndrome surfaces clinically, the likelihood of cardiac involvement is 50%. Although medical therapies such as somatostatin analogues may provide some symptom relief, they offer no mortality benefit. On the other hand, referral to surgery following early detection has shown increased survival. The prompt recognition of this disease is therefore of the utmost importance.
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Carrilho-Ferreira P, Silva D, Almeida AG, Infante de Oliveira E, Ferreira C, Miranda L, Rosa R, Canas da Silva P, Bicha Castelo H, Nunes Diogo A. Carcinoid heart disease: outcome after balloon pulmonary valvuloplasty. Can J Cardiol 2012; 29:751.e7-9. [PMID: 23228489 DOI: 10.1016/j.cjca.2012.09.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Revised: 09/22/2012] [Accepted: 09/25/2012] [Indexed: 11/26/2022] Open
Abstract
Carcinoid heart disease typically presents with pulmonary stenosis and tricuspid regurgitation. Management is intended for symptomatic relief, and valvular intervention is indicated in refractory heart failure. Balloon valvuloplasty is an option for patients not suitable for surgery. We report the case of a patient with a carcinoid tumour, who developed postoperative refractory hypoxemia. Transthoracic echocardiogram revealed carcinoid pulmonary and tricuspid valve disease, with severe pulmonary stenosis. Balloon valvuloplasty was performed with major clinical improvement.
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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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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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Affiliation(s)
- Sanjeev Bhattacharyya
- Carcinoid Heart Disease Clinic, Department of Cardiology, Royal Free Hospital, Pond St, London, NW3 2QG, UK
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Zarzur J, Daherddine A, Housni A, Balafrej K, Zaidi K, Benmimoun EG, Arharbi M. [Heart involvement in carcinoid syndrome: report of a case]. Ann Cardiol Angeiol (Paris) 2001; 50:412-5. [PMID: 12555635 DOI: 10.1016/s0003-3928(01)00049-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The authors report the case of tricuspid and pulmonary disease, revealing a carcinoid syndrome in a 32 years-old young man who was admitted for asthenia and an effort hepatology. The carcinoid syndrome was confirmed by hormonal proportioning, and by an anatomopathologic and immunohistochimic study of a hepatic metastatic biopsy. The check-up to search the primitive tumor was negative. The clinicals, paraclinicals and therapeutics aspects of the carcinoid heart were reported in this work.
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Affiliation(s)
- J Zarzur
- Service de cardiologie B, maternité Souissi, Rabat, Maroc
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Abstract
Half of all patients with carcinoid syndrome develop cardiac involvement. Patients who have cardiac involvement have a significantly worse prognosis than those without, and death can occur directly as a result of cardiac involvement. A case of carcinoid syndrome in a 38 year old woman with lesions in the liver, who presented with right sided valvar abnormalities, a dilated right ventricle, and right ventricular pressure overload, is presented. In order to palliate the patient's symptoms and to decrease right sided pressures before major abdominal surgery, balloon pulmonary valvuloplasty was performed at the time of cardiac catheterisation. This resulted in a reduction in the pulmonary gradient and right ventricular pressure. Following the procedure, the patient's symptoms were completely relieved. She went on to laparotomy where the lesions in the liver were excised without complication.
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Affiliation(s)
- O Obel
- Cardiothoracic Centre, Guy's and St Thomas Hospital NHS Trust, London, UK.
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Abstract
Carcinoid syndrome originates from metastatic carcinoid tumors localized in the gastrointestinal system, pancreas, biliary vessels, bronchi, ovaries, and testes; it is characterized by flushing, telangiectasias, diarrhea, bronchoconstriction, and fibrous endocardial plaques in the heart. Cardiac involvement is detected by echocardiography in over 50% of patients with this syndrome. Right-sided valvular heart disease occurs frequently in patients with carcinoid syndrome, involving most commonly the tricuspid and pulmonary valves. Involvement of the left-sided valves rarely occurs. Medical therapy for carcinoid heart disease includes digitalis and diuretics for congestive heart failure symptoms; the effects of carcinoid syndrome can be treated with the use of somatostatin analogues. Conventional chemotherapy has been of little beneficial value, with response rates of only 10% to 30%. The use of octreotide, a long-acting and potent somatostatin analogue, is a major advance in the management of carcinoid tumors. In addition to providing effective symptom relief in malignant carcinoid syndrome, octreotide can also be used for diagnostic purposes. Despite its expense, octreotide is the current agent of choice for the treatment of this condition. Analogues with different receptor specificities and pharmacokinetics hold promise for the future. Valve surgery is the only definitive treatment for intractable right-sided heart failure. Although cardiac surgery carries high perioperative mortality, marked symptomatic improvement occurs in survivors. Surgical intervention therefore should be considered in the appropriate patients when cardiac symptoms become severe. Balloon valvulotomy in patients with severe pulmonary artery stenosis often results in palliation of symptoms; however, surgery still is required often in these patients.
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Ohri SK, Schofield JB, Hodgson H, Oakley CM, Keogh BE. Carcinoid heart disease: early failure of an allograft valve replacement. Ann Thorac Surg 1994; 58:1161-3. [PMID: 7944771 DOI: 10.1016/0003-4975(94)90479-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A woman who had carcinoid syndrome and carcinoid heart disease underwent tricuspid and pulmonary valve replacements with a xenograft and a cryopreserved allograft, respectively. Within 3 months of the operation severe pulmonary regurgitation and pulmonary hypertension refractory to medical therapy developed. Autopsy found the biomechanical tricuspid valve to be free of disease but the allograft in the pulmonary position was involved by carcinoid heart disease in a fashion similar to the excised native pulmonary valve.
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Affiliation(s)
- S K Ohri
- Department of Surgery, Hammersmith Hospital, Royal Postgraduate Medical School, London, England
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Hargreaves AD, Pringle SD, Boon NA. Successful balloon dilatation of the pulmonary valve in carcinoid heart disease. Int J Cardiol 1994; 45:150-1. [PMID: 7960257 DOI: 10.1016/0167-5273(94)90274-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Percutaneous balloon dilatation of the pulmonary valve resulted in long lasting benefit in a 40-year-old patient with carcinoid heart disease. Concomitant aggressive therapy for her metastatic carcinoid tumour may explain why the clinical outcome was better than previous reports.
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Affiliation(s)
- A D Hargreaves
- Department of Medicine, Royal Infirmary of Edinburgh, UK
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