P042: WHEN TWO BECOMES THREE: THE IMPORTANCE OF INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAM DURING SURGERY FOR CARCINOID HEART DISEASE
Anna S Jenkins1; Ross J Renew, MD2; Anna B Shapiro, MD2; Ashley V Fritz, DO2; 1Mayo Clinic Alix School of Medicine; 2Mayo Clinic Florida
Introduction: A rare cause of acquired heart disease, carcinoid heart disease (CHD) is a major cause of mortality and morbidity to patients with carcinoid syndrome. Impacting 20-60% of patients with carcinoid tumors, CHD results from circulating vasoactive peptides which contributes to plaque-like fibrous deposits around cardiac valves. CHD predominantly effects right-sided valves, with the lungs metabolizing vasoactive peptides before they can enter left-sided circulation. Left-sided disease has, however, been reported in patients with bronchial carcinoid, patient foramen ovale (PFO), or disease so severe and uncontrolled, it overwhelms the pulmonary degradation capacity.
Valvular surgery is the only definitive treatment for CHD. Perioperative management of these cases can be challenging. Carcinoid tumors can secrete a variety of vasoactive amines, most commonly serotonin and histamine, and preoperative optimization focused on antagonizing these amines. Somatostatin analogs such as octreotide are a mainstay of treatment [1,2]. Perioperatively, there is the risk of carcinoid crisis—an uncontrolled release of vasoactive substances from tumor stimulation. It is imperative the anesthesiologist is knowledgeable in peri-operative management. While transthoracic echocardiogram (TTE) is the diagnostic standard and directs preoperative planning, transesophageal echocardiogram (TEE) is essential for intraoperative monitoring and evaluation. This report describes the perioperative management of a CHD and how intraoperative TEE findings changed the operative plan.
Methods/Case Report: A 51-year-old man was admitted for elective tricuspid and pulmonary valve replacement for severe tricuspid regurgitation secondary to carcinoid syndrome and stage IV small bowel carcinoid tumor, managed with octreotide therapy. Previously an avid exerciser, the patient began experiencing worsening fatigue, dyspnea, orthopnea, and peripheral edema. TTE indicated severe tricuspid regurgitation, pulmonic stenosis, mild aortic regurgitation and preserved biventricular systolic function. A cardiac stress test was negative for ischemic EKG changes; however the patient became hypotensive during the test. Preoperative vitals were significant for a SpO2 of 88% on room air.
The patient was taken to the operating room for surgical intervention. Intraoperative TEE revealed a PFO and severe right-to-left shunting, as well as severe aortic and pulmonic valve regurgitation. These findings were discussed with the surgical team, and the surgical plan was expanded to include tricuspid, pulmonic, aortic valve replacement with PFO closure. Throughout the procedure, the patient was on a continuous octreotide drip (of 250mcg/mL at 25-200 mL/h) of and received 4 boluses of 100 mcg. The surgical course was uneventful and the patient was hemodynamically stable. The patient was taken to the ICU and managed postoperatively on continued octreotide infusion.
Conclusion: This case describes the intraoperative discovery of left-sided CHD with subsequent modification of surgical plan. This case underscores the importance of intraoperative transesophageal echocardiogram and demonstrates its potential impact on surgical management.
1. Dobson R, Burgess MI, Pritchard DM, Cuthbertson DJ. The clinical presentation and management of carcinoid heart disease. International Journal of Cardiology. 2014;173(1):29-32. doi:10.1016/j.ijcard.2014.02.037
2. Castillo J, Silvay G, Weiner M. Anesthetic Management of Patients With Carcinoid Syndrome and Carcinoid Heart Disease: The Mount Sinai Algorithm. Journal of Cardiothoracic and Vascular Anesthesia. 2018;32(2):1023-1031. doi:10.1053/j.jvca.2017.11.027