Intraoperative transesophageal two-dimensional echocardiography for the detection of carcinoid heart disease
Ralph J. Fuchs, M.D., Monica Botero, M.D., David Paulus M.D.
Dept of Anesthesiology, University of Florida
Veterans Affairs Medical Center, Gainesville, Florida
Introduction: The carcinoid syndrome is a rare cause of acquired
valvular heart disease. However, cardiac involvement has been
recognized in more than half the patients with this syndrome
(1), and it may be the cause of death in this condition (2). We
report the preoperative misdiagnosis of carcinoid syndrome in a
patient that presented for elective exploratory laparotomy, and
resection of pelvic masses of unknown etiology. Intraoperative
transesophageal echocardiography demonstrated right-sided
valvular heart lesions, which suggested the diagnosis before a
pathological confirmation was obtained.
Case Report: A 51 year old woman presented to her primary care
physician with increasing abdominal discomfort, diarrhea, facial
flushing, cough, and anxiety attacks. She was referred to a
gynecologist because of abdominal masses with ascites. The
patient was scheduled for a total abdominal hysterectomy and
bilateral salpingo-oophorectomy because of suspected ovarian
carcinoma. General anesthesia induced with intravenous
thiopental and maintained isoflurane and fentanyl. After
placement of a central venous catheter, high central venous
pressure was noted and continued throughout the procedure
despite hemorrhage due to surgical dissection. A CVP tracing
showed large v-waves. Intraoperative transesophageal
two-dimensional echocardiography demonstrated an enlarged right
atrium, an abnormal tricuspid valve, and tricuspid insufficiency
(see figure). The tricuspid valve leaflets appeared thick,
short, retracted and showed restricted movement, resulting in
incomplete coaptation. The pulmonic valve appeared thickened and
retracted. Postoperative urine 5-HIAA was elevated. The final
histopathological examination showed bilateral ovarian
metastatic carcinoid ovarian tumors with metastatic carcinoid
tumor.
Discussion: The exposure of the endocardium to the elevated
levels of serotonin might lead to the development of heart
lesions, but the exact pathogenesis remains unknown. This case
report discusses the classical presentation and anesthetic
management of patients with carcinoid syndrome and emphasizes
the importance of a proper preoperative diagnosis and careful
planning if the incidence and severity of the symptoms provoked
is to be reduced.
References:
1. Roberts WC, Sjoerdsma A: The cardiac disease associated with
the carcinoid syndrome (carcinoid heart disease). Am J Med
1964;36:5-34
2. Pellikka PA, Tajik AJ, Khandheria BK et al: Carcinoid heart
disease: clinical and echocardiographic spectrum in 74 patients.
Circulation 1993; 87:4;1188-1196
