Echocardiographic features of carcinoid heart disease

[Tricuspid insufficiency disclosing carcinoid syndrome]

The authors present a case of tricuspid regurgitation which reveals a carcinoid syndrome in an 68 year-old woman discovered in view of right heart failure. This carcinoid heart disease is early without symptoms of the primitive or the liver metastatic tumors. We see a good evolution with somatostatin's analogue. We review the diagnosis features in trans-thoracic and trans-oesophageal echocardiography, and the possibility of surgical treatment of these lesions.

Carcinoid heart disease. A cardiologist's viewpoint

In patients with malignant midgut carcinoid tumors, characteristic cardiac abnormalities can be demonstrated by cardiac ultrasound in 60-70%. These ultrasound findings include morphological and functional changes of the tricuspid and pulmonary valves, enlargement of the right heart cavities and paradoxical septal contraction pattern. In patients with severe carcinoid heart disease leading to right ventricular failure, reconstructive valvular surgery is of obvious beneficial value and should be considered when the malignant disease is under control and clinical signs of right heart failure cannot be managed medically. The pathognomonic carcinoid lesions are mainly located on the right side of the heart and consists microscopically of fibrous tissue superimposed on mural and valvular endocardium. Infiltration into underlying endocardium and myocardium has been demonstrated. The etiology of carcinoid heart disease remains obscure. The extent of the cardiac disease seems related to circulating tumor-released substances such as serotonin and tachykinins.

Carcinoid heart disease: relationship of circulating vasoactive substances to ultrasound-detectable cardiac abnormalities

Cardiac ultrasound investigation of 68 prospectively studied patients with histologically proven midgut carcinoid tumors showed right heart disease in 66%. The abnormal findings included morphologic and functional aberrations of the tricuspid valve in 52% and 83%, respectively, right atrial and ventricular enlargement in 53% and 30%, and paradoxical systolic septal contractions in 19%. The patients with the most pronounced right heart disease had significantly higher (p less than .01) plasma levels of the tachykinins neuropeptide K and substance P as well as higher (p less than .001) urinary excretion of the serotonin metabolite 5-hydroxyindoleacetic acid. These patients also had the most extensive tumor disease. The occurrence of echocardiographic abnormalities of the left heart was similar to that in healthy individuals of the same age, but abnormalities were less frequent among the patients with severe right heart disease. Electrocardiographic changes were nonspecific. Right heart disease thus seems to be present more often than previously reported in patients with malignant midgut carcinoid tumors. The severity of cardiac involvement does not seem to be related to the duration of carcinoid disease but more to the extent of the disease, i.e., higher plasma levels of serotonin and tachykinins.