Early and Late Outcomes of Surgical Treatment in Carcinoid Heart Disease

Abstract

Operative mortality associated with valve replacement surgery for CaHD has decreased. Symptomatic and survival benefit is noted in most patients when CaHD is managed by an experienced multidisciplinary team.

Carcinoid Heart Disease and Review of Literature

“…17,18 Without surgery, only 10% of the patients will survive after 2 years of onset of New York heart association (NYHA) functional class III and IV symptoms. 18 The optimal timing of surgery in relation to the signs and symptoms of severe valvular dysfunction has not been clearly defined. Further more, perioperative mortality for those undergoing valve replacement remains high.…”

Cardiac Surgery for Carcinoid Heart Disease: A Weapon Not to Be Misused

“…A substantial decrease in mortality rates between the 2 study periods (28 vs. 6%, p = 0.004) was reported, which was attributed by the authors to changes in preoperative and intraoperative management, such as the use of aprotinin, shorter duration of cardio-pulmonary bypass and aortic cross-clamping, and increased implementation of PV replacement rather than valvotomy. In a recent study, Connolly et al [36] reported the short- and long-term outcomes of the largest case series (n = 195) of consecutive patients submitted to cardiac surgery for CHD treatment at the same center (Mayo Clinic, Rochester, N.Y., USA) over a 27-year period, between 1985 and 2012. Tricuspid, pulmonary, mitral, or aortic valve disease that warranted intervention was detected in 195, 157, 21, and 18 patients, respectively.…”

“…Among these, the most prominent seems to be the comparative efficacy and safety of the 2 types (bioprosthetic vs. mechanical) of prosthetic valves used. Although anecdotal reports have described premature degeneration of the implanted bioprosthetic valve (as early as 3 months postoperatively) and attributed the disorder to elevated 5-HIAA levels [46,47], more recent data have demonstrated the safety and longevity of bioprosthetic valves [36]. Furthermore, one must highlight the existence of a trend for increased survival among the patients who had received bioprosthetic versus mechanical valves in the same cohort.…”

“…Indirect data pertaining to: (a) the decreased survival span once symptoms of overt HF present [9], (b) the exclusion of patients with severe RHF from cardiac surgery or the unfavorable outcomes in the presence of RHF [42,49], (c) the difference in survival between patients with and without cardiac involvement [8], (d) the improvements in postoperative survival over the last decades [31,35], and (e) the use of novel imaging techniques, such echocardiographic LV and RV strain [50,51], which has been accompanied by incremental diagnostic and prognostic value over traditionally recommended conventional echocardiographic indices, has created a trend toward the application of heart surgery upon echocardiographic detection of CHD, prior to the appearance of symptoms of RHF [52]. However, the recent, large study by Connolly et al [36] failed to demonstrate an independent association between preoperative: (a) presence of advanced HF (NYHA III or IV), (b) signs of RHF (ascites, leg edema), (c) echocardiographic findings of RV dysfunction, and (d) time from carcinoid diagnosis and operation, and cumulative postoperative survival. On the other hand, anasarca edema and the need for intravenous diuretics prior to cardiac surgery independently predicted perioperative mortality.…”

“…Given that uncontrolled carcinoid disease and comorbidities represent contraindications for heart valve surgery in a significant proportion of patients with CHD [33,36,42], innovative, minimally invasive interventions may be implemented for this subpopulation. The first cases demonstrating the feasibility and safety of such techniques have been recently reported [54,55].…”