Molecular biology of carcinoid heart disease: Seeking therapeutic targets in the era of targeted therapy

Carcinoid tumors (CT) are among the least studied tumors. It is a relatively rare and slow-growing tumor with good survival in its primary form. However, metastatic carcinoid tumor comes up with many different complications contributing to increased morbidity and mortality. Metastatic form of the disease has a wide spectrum of clinical manifestations and multisystem involvement including cardiovascular manifestations, neurological manifestations, and psychiatric manifestations and so on. In this review, we are centered towards the cardiovascular manifestations of the disease, which, by far, is one of the commonest causes of death in these patients. Being a neuroendocrine tumor, cardiovascular manifestations are mainly because of biologically active substances, produced by the tumor cells, remodeling the heart. Development of targeted therapies against carcinoid heart diseases is currently limited by lack of understanding of pathophysiology of the disease processes. In this review, we aim to figure out the spectrum of carcinoid heart diseases, along with the molecular biology of the changes going on, which, in turn, will not only pave a way to the development of targeted therapies but will also extend opportunities for molecular screening of the tumor and diagnosis at an early stage, thereby, reducing the morbidity and mortality.

The Past, Present, and The Future of Carcinoid Heart Disease

Carcinoid heart disease is a frequent manifestation of carcinoid syndrome. It results from the release of a large amount of serotonin and subsequently fibrosis of right sided heart valves, that is, tricuspid and pulmonic valve. This article reviews the pathogenesis, clinical symptoms, diagnosis, treatment and prognosis of carcinoid heart disease. Recent developments in treating carcinoid heart disease have improved the poor prognosis associated with the disease.

Carcinoid heart disease in patients with midgut neuroendocrine tumours

Carcinoid heart disease (CHD) is the main complication of carcinoid syndrome (CS) associated with metastatic small intestine neuroendocrine tumours (NETs). The pathophysiology of CHD is partly understood but vasoactive hormones secreted by NETs, especially serotonin, play a major role, leading to the formation of fibrous plaques. These plaque-like deposits involve the right side of the heart in >90% of cases, particularly the tricuspid and pulmonary valves, which become thickened, retracted and immobile, resulting in regurgitation or stenosis. CHD represents a major diagnostic and therapeutic challenge for patients with NET and CS and is associated with increased risk of morbidity and mortality. CHD often occurs 2-5 years after the diagnosis of metastatic NET, but diagnosis of CHD can be delayed as patients are often asymptomatic for a long time despite severe heart valve involvement. Circulating biomarkers (5HIAA, NT-proBNP) are relevant tools but transthoracic echocardiography is the key examination for diagnosis and follow-up of CHD. However, there is no consensus on the optimal indications and frequency of TTE and biomarker dosing regarding screening and diagnosis. Treatment of CHD is complex and requires a multidisciplinary approach. It relies on antitumour treatment, control of CS and surgical valve replacement in cases of severe CHD. However, cardiac surgery is associated with a high risk of mortality, notably due to perioperative carcinoid crisis and right ventricular dysfunction. Timing of surgery is the most crucial point of CHD management and relies on the case-by-case determination of the optimal compromise between tumour progression, cardiac symptoms and CS control.

Synoptic reporting of echocardiography in carcinoid heart disease (ENETS Carcinoid Heart Disease Task Force)

BACKGROUND

This European Neuroendocrine Tumor Society (ENETS) Expert Consensus document aims to provide practical guidance and standardization for echocardiography in the screening and follow-up of carcinoid heart disease (CHD) in patients with a neuroendocrine tumour (NET) and carcinoid syndrome.

METHODS

NET experts within the ENETS Carcinoid Heart Disease Task Force reviewed both general reporting guidelines and specialized scoring systems for transthoracic echocardiography (TTE) in CHD. Based on this review, a dedicated template report was designed by the multidisciplinary working group of cardiologists, oncologists, endocrinologists, gastroenterologists, surgeons and radiologists.

RESULTS

We propose a Synoptic Reporting of Echocardiography in Carcinoid Heart Disease which represents an agreed peer reviewed proforma to capture information at the time of referral and enable a detailed outcome of CHD assessment. This includes a systematic and detailed list of structures to evaluate data to capture at the time of reporting of TTE.

CONCLUSIONS

Adherence to these reporting guidelines aims to promote homogeneous and detailed evaluation of CHD to secure accurate assessment and allow comparison of studies performed intra- and inter-individually. These guidelines could also facilitate CHD assessment as part of prospective clinical trials to enable standardization of the findings seen in response to therapy.

Update in carcinoid heart disease - the heart of the matter

Carcinoid heart disease (CHD) is a paraneoplastic cardiac manifestation occurring in patients with carcinoid syndrome (CS) and advanced neuroendocrine malignancy. In about 20-40% of patients with CS, chronic exposure to tumor-released circulating vasoactive peptides typically results in right-sided valvular fibrosis leading to valve dysfunction and right heart failure. CHD remains a significant cause of morbidity and mortality. The management of patients with CHD is complex, as both the systemic malignant disease and the heart involvement have to be addressed. Early diagnosis and timely surgical intervention in selected patients are of utmost importance and offer a survival benefit. In patients with advanced carcinoid heart disease, valve replacement surgery is the most effective option to alleviate cardiac symptoms and contribute to survival outcomes. A collaboration of a multidisciplinary team in centers with experience is required to provide optimal patient management. Here, we review the current literature regarding CHD presentation, pathophysiology, diagnostic tools, and available treatment strategies.

Carcinoid syndroma - diagnosis and management

Neuroendocrine tumors (NETs, originally termed “carcinoids”) create a relatively rare group of neoplasms with an approximate incidence rate of 5 to 8 cases per 10 000 persons. NETs predominantly demonstrate indolent disease biology for many years. They become symptomatic when they are large enough or when they metastasize to the liver or the lungs, bones, or other sites. Roughly 30% to 40% of subjects with NETs develop carcinoid syndrome. Signs and symptoms of carcinoid syndrome are bronchospasm, flushing, diarrhea and cramping, cyanosis and pellagra. White plaque-like deposits on the endocardial surface of heart structures are characteristic for carcinoid heart disease. The treatment of patients with carcinoid syndrome is multi-faceted due to the necessity to manage simultaneously the systemic cancer disease as well as the signs of carcinoid syndrome and includes resection or debulking of tumor mass, biological treatment with somatostatin analogues and peptide receptor radionuclide treatment.

Cases in a series of carcinoid syndrome and carcinoid heart disease

Although carcinoid syndrome is regarded as a rare entity, carcinoid patients with evidence of cardiac involvement show a markedly reduced survival time. Patients with advanced signs of right-sided heart failure represent a subgroup at particularly high risk. Echocardiography remains the gold standard to diagnose or confirm structural cardiac involvement in patients with underlying carcinoid disease. This is the notion that propelled us to report on cases of carcinoid syndrome with cardiac involvement. We also review carcinoid syndrome and carcinoid heart disease, and challenges regarding the diagnosis and management of carcinoid heart disease.

Carcinoid Heart Disease: Review of Current Knowledge

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.

Carcinoid Heart Disease: Review of Current Knowledge

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.

Carcinoid Heart Disease: A Review

Carcinoid heart disease remains a major cause of morbidity and mortality among patients with carcinoid syndrome and metastatic neuroendocrine tumors. Screening of all patients with N-terminal pro-B-type natriuretic peptide and transthoracic echocardiography is critical for early detection, as early symptoms and signs have low sensitivity for the disease. Cardiac surgery, in appropriate cases, is the only definitive therapy for advanced carcinoid heart disease, and it improves patient symptoms and survival. Management of carcinoid heart disease is complex, and multidisciplinary assessment of cardiac status, hormonal syndrome, and tumor burden is critical in guiding optimal timing of surgery.

Carcinoid syndrome: update on the pathophysiology and treatment

Approximately 30-40% of patients with well-differentiated neuroendocrine tumors present with carcinoid syndrome, which is a paraneoplastic syndrome associated with the secretion of several humoral factors. Carcinoid syndrome significantly and negatively affects patients' quality of life; increases costs compared with the costs of nonfunctioning neuroendocrine tumors; and results in changes in patients' lifestyle, such as diet, work, physical activity and social life. For several decades, patients with neuroendocrine tumors and carcinoid syndrome have been treated with somatostatin analogues as the first-line treatment. While these agents provide significant relief from carcinoid syndrome symptoms, there is inevitable clinical progression, and new therapeutic interventions are needed. More than 40 substances have been identified as being potentially related to carcinoid syndrome; however, their individual contributions in triggering different carcinoid symptoms or complications, such as carcinoid heart disease, remain unclear. These substances include serotonin (5-HT), which appears to be the primary marker associated with the syndrome, as well as histamine, kallikrein, prostaglandins, and tachykinins. Given the complexity involving the origin, diagnosis and management of patients with carcinoid syndrome, we have undertaken a comprehensive review to update information about the pathophysiology, diagnostic tools and treatment sequence of this syndrome, which currently comprises a multidisciplinary approach.

Carcinoid Heart Disease: From Pathophysiology to Treatment--'Something in the Way It Moves'

Carcinoid heart disease (CHD) is a rare cardiac manifestation occurring in patients with advanced neuroendocrine tumours and the carcinoid syndrome, usually involving the right-sided heart valves and eventually leading to right heart failure. The pathophysiology of CHD is still obscure and believed to be multifactorial, as a variety of vasoactive substances secreted by the tumour appear to be involved. The management of patients with CHD is complex, as both the systemic malignant disease and the heart involvement have to be addressed. Timely diagnosis and early surgical treatment in appropriately selected patients are of outmost importance, as CHD is associated with increased morbidity and mortality. Valve replacement surgery alleviates right heart failure and may also contribute to improved survival. In the present study we have comprehensively reviewed the existing literature to date, mainly focusing on the pathophysiology of CHD. Other aspects of CHD (such as the clinical presentation, diagnostic tools and therapeutic approach) are addressed in brief.

Resolution of right-sided heart failure symptoms after resection of a primary ovarian carcinoid tumor

Carcinoid tumors are rare neuroendocrine malignancies that typically originate from the gastrointestinal tract. Patients who are diagnosed with carcinoid heart disease generally have poor prognoses because of advanced metastases during staging and few therapeutic options. We present the case of a 61-year-old woman with right-sided heart failure, secondary to carcinoid heart disease caused by a primary ovarian carcinoid tumor. After undergoing surgical resection of the left ovary and fallopian tube, the patient experienced complete resolution of her heart failure symptoms. In addition to the patient's case, we discuss the diagnosis, nature, and treatment of this rare condition.

Metastatic carcinoid disease inducing coronary vasospasm

Herein, we report a case of progressive coronary vasospasm in a 70-year-old man who had a long-standing history of metastatic gastrointestinal carcinoid tumor. Despite octreotide, nitrate, and calcium channel-blocker therapy, the patient's urinary 5-hydroxy-indole acetic acid level increased, coinciding with an increased frequency of flushing episodes with chest discomfort. In the cardiac catheterization laboratory, we captured an episode that was associated with diffuse right coronary artery spasm, ST-segment elevation, and intense symptoms. We attribute the patient's coronary vasospasm to his metastatic carcinoid disease.

Long-term survival and nearly asymptomatic course of carcinoid tumour with multiple metastases (treated by surgery, chemotherapy, (90)Y-DOTATATE, and LAR octreotide analogue): a case report

Carcinoids are the most common neuroendocrine tumours. They are usually slowly growing, located in the small intestine, secrete serotonin, and are characterized by long survival of patients, so prognosis is generally good. The most frequently encountered clinical presentations of carcinoids are intermittent abdominal pain and carcinoid syndrome (diarrhoea and flushing). Metastases worsen the prognosis and limit the survival of the patients. We report a case of carcinoid tumour with primary focus in the ileum, with an appendix infiltration, in a thirty-two-year-old woman with acute appendicitis symptoms only. Carcinoid was diagnosed postoperatively by histopathological examination. Nowadays, twenty-five years after the surgery, there is evidence of nearly asymptomatic numerous metastases. Only intermittent abdominal pain for about 1-2 years was reported. Partial metastases resection was performed, followed by chemotherapy, (90)Y-DOTATATE and then long-acting release octreotide analogue therapy. In the meantime, severe chronic heart failure (NYHA IV) due to tricuspid combined valvular heart disease and pulmonary hypertension was diagnosed. Combined therapy, typical for chronic heart failure, together with long-acting octreotide analogue highly improved the patient's heart sufficiency and reduced carcinoid syndrome symptoms. The only adverse events of octreotide therapy were hyperbilirubinaemia and itching. Long-term survival is typical for carcinoids, but 30-years survival has not been described in the literature yet.

Carcinoid heart disease--a hidden complication of neuroendocrine tumours

Carcinoid heart disease (CHD) develops in serotonin-producing neuroendocrine tumours (NET) due to fibrotic endocardial plaques with associated valve dysfunction leading most often to right-sided heart failure. The classical carcinoid syndrome usually occurs when serotonin-producing NET metastasize to the liver. Up to 50% of those patients will exhibit carcinoid heart disease. The pathophysiological process is not yet completely understood: serotonin is considered to be a major initiator of the fibrotic process, but other tumour secreted factors may contribute to the pathogenesis. Histopathology reveals intact valvular cusps with superimposed fibrotic plaques, leading to thickening and retraction of the valves, causing valvular dysfunction. A high index of clinical suspicion to diagnose CHD is needed since symptoms can be rather non-specific. Transthoracic echocardiography is the gold standard for diagnosis and should probably be performed at the time of diagnosing serotonin-producing NET and then repeated annually. On the other hand, when diagnosing right-heart failure, the presence of CHD and underlying serotonin-producing NET should be taken into account. Therapeutic options include pharmacotherapy for heart failure, control of the systemic carcinoid disease and in selected individuals cardiac valve replacement. The elucidation of the pathologic process is necessary to develop targeted antifibrotic therapeutic agents since CHD seems to be irreversible and associated with poor prognosis.

Carcinoid crisis and reversible right ventricular dysfunction after embolization in untreated carcinoid syndrome

A 59-year-old white male with carcinoid tumor and hepatic metastases underwent hepatic artery embolization. The patient developed carcinoid crisis and a subsequent transthoracic echocardiogram showed classic findings of carcinoid heart disease along with a dilated hypertrophied right ventricle and severely depressed right ventricular ejection fraction. After treatment with octreotide the patient's clinical condition improved and a repeat transthoracic echocardiogram showed a significant improvement and normalization of right ventricular systolic function. Serotonin levels showed a progressive decline that correlated well with the patient's improved clinical condition. These findings suggest that the acute right ventricular dysfunction was secondary to acute carcinoid crisis and resolution resulted in a significant improvement of both right ventricular systolic function and clinical condition.

Carcinoid heart disease

Carcinoid heart disease is a rare form of valvular heart disease. The management of these patients is complex, as the systemic malignant disease and the cardiac involvement have to be considered at the same time. Progress in the treatment of patients with carcinoid disease has resulted in improved symptom control and survival. Development and progression of carcinoid heart disease are associated with increased morbidity and mortality. In patients with severe cardiac involvement and well-controlled systemic disease, cardiac surgery has been recognized as the only effective treatment option. Valve replacement surgery may not only be beneficial in terms of symptom relief, but may also contribute to the improved survival observed over the past 2 decades in patients with carcinoid heart disease. Early diagnosis and early surgical treatment in appropriately selected patients may provide the best results. In this article, we review the current literature regarding the biology, diagnosis, treatment, and prognosis of carcinoid heart disease.

Isolated Tricuspid Stenosis and Heart Failure: a Focus on Carcinoid Heart Disease

A rare clinical occurrence, heart failure in the setting of tricuspid stenosis should immediately trigger a search for underlying systemic carcinoid disease. Carcinoid tumor cells can secrete a variety of vasoactive substances that result in skin erythema, excretory diarrhea, bronchospasm, and hemodynamic instability, but these manifestations are noted only in a few patients. Right heart valvular disease is common since the vasoactive noxious substances pass through the right heart unaffected and undergo metabolism in the pulmonary circulation, thereby decreasing involvement of the left-sided valves. Localization of the carcinoid tumor followed by surgically directed valvular treatment is mandatory for relief of symptoms. In nonoperative candidates, cytotoxic chemotherapy or long-term symptomatic drug treatment with somatostatin is indicated.

Carcinoid case presentation and discussion: the American perspective

The rationale underlying an aggressive approach in the management of some carcinoid patients is explained and illustrated by the presented case of a middle-aged man with advanced classic typical midgut carcinoid. The patient exhibited somatostatin receptor scintigraphy-positive massive liver metastases, carcinoid syndrome, severe tricuspid and pulmonic cardiac valve disease with congestive heart failure, ascites and malnutrition. He had been treated for several years with supportive medications and biotherapy including octreotide and alpha interferon but his tumor eventually progressed and his overall condition was markedly deteriorated when he first sought more aggressive treatment. This consisted of prompt replacement of both tricuspid and pulmonic valves, followed by hepatic artery chemoembolus (HACE) injection and then surgical tumor debulking including excision of the primary tumor in the small intestine. In addition, radiofrequency ablation was utilized to reduce the volume of metastases in the liver. Prophylactic cholecystectomy was also performed and a biopsy of tumor was submitted for cell culture drug resistance testing. This was followed by systemic chemotherapy utilizing the drug (docetaxel) which the in vitro studies suggested as most likely to be effective. His excellent response to this succession of treatments exemplifies the successful application of aggressive sequential multi-modality therapy.

Carcinoid heart disease: an update

BACKGROUND

Carcinoid tumours are a poorly defined collection of lesions, histopathologically indistinguishable from gastroentero-pancreatic neuroendocrine tumours. In this report, we discuss epidemiology and survival, clinical presentation, carcinoid valvular heart disease (CVHD), histopathological considerations and treatment options.

METHODS

Review and update of the literature.

RESULTS

The term carcinoid suggests a disease entity, but with increasing knowledge it becomes progressively confusing. To avoid further confusion, it is advisable to define these tumours using differentiation, stage, primary site, known tumour products and an associated clinical syndrome. Incidence varies between 0.8 and 1.9/100,000 population. About 20% present with metastases, with a 5-year survival varying between 15% and 35%. Metastatic disease frequently accompanies the carcinoid syndrome (flushing, diarrhoea, wheezing and CVHD). CVHD incidence is about 50%, and seems unrelated to disease duration and tumour mass. An aetiological relation of CVHD with urinary 5-HIAA remains to be confirmed. Resection is the only curative option. Surgery can also offer prolonged palliation and is needed to restore bowel transit in obstructive/ischaemic bowel problems. Adequate palliation of hormone-related symptoms can also be achieved by somatostatin analogues, meta-iodo-benzyl-guanidine preparations and interferon-alpha formulations, all with a 70% response rate. Embolization of liver metastases has led to objective responses in about 50% of patients, but is accompanied by significant side effects.

CONCLUSIONS

Most patients are cured by surgery. Symptom relief is the main target in metastatic disease and can be achieved by a range of equally potent biologically active medications, debulking surgery and hepatic embolization.

[Carcinoid tumors]

Carcinoids are characteristically indolent, but heterogeneous tumors with respect to their site of origin, endocrine features, clinical manifestations and biologic behaviour. The authors summarize the current laboratory, endoscopic and radiologic methods used for the diagnosis of carcinoid tumors. Treatment modalities should be directed against the tumor and the hormonal excess state. The authors review the outcome of most frequently used therapies, including somatostatin-analogue and interferon treatment, chemotherapy, embolization, receptor-targeted radiotherapy and surgical intervention). Patients with carcinoid tumors, with or without carcinoid syndrome, are best managed by a multidisciplinary approach.

Echocardiographic diagnosis in carcinoid heart disease

In this case report the typical echocardiographic features of carcinoid heart disease are presented. Newer treatments such as the use of a somatostatin analogue, interferon and hepatic de-arterialisation have improved the prognosis in patients with carcinoid syndrome. Nevertheless this syndrome portends a poor prognosis in patients with cardiac involvement. Cardiac lesions are mainly located in the right side of the heart. Regurgitation and stenosis of the tricuspid and pulmonary valve, leading to right heart failure, are the most common cardiac manifestations of the disease. Elevated levels of serotonin are probably responsible for the development of these cardiac lesions. Despite treatment resulting in significant reductions of urinary levels of 5-HIAA, regression of the cardiac manifestations in carcinoid syndrome has not been observed. Two-dimensional and Doppler echocardiography are the main tools to establish the diagnosis and severity of carcinoid heart disease. Cardiac surgery for carcinoid heart disease might improve symptoms and longevity, but the scarce data report on early mortality of over 35%.

The carcinoid syndrome: an unusual cause of valvular heart disease

A 30-year-old woman presented to the Emergency Department with complaints of shortness of breath, orthopnea, and a severe reduction in exercise tolerance. The symptoms were the result of severe valvular heart disease that resulted from a bronchopulmonary carcinoid tumor. The carcinoid syndrome is a distinctive clinical syndrome seen in patients with carcinoid tumors. Cardiac valvular lesions are seen in the majority of patients with the carcinoid syndrome and represent the most clinically significant consequence of the carcinoid syndrome. This case report discusses carcinoid tumors, the carcinoid syndrome induced by these tumors, and the therapeutic options in the management of carcinoid tumors.

Balloon pulmonary valvuloplasty in carcinoid syndrome

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.

[Use of echocardiography in the diagnosis of carcinoid tumors. Report of 4 cases]

Carcinoid tumours are the most common neuro-endocrine tumours but cardiac involvement is rarely symptomatic although often observed at post-mortem and rarely revelatory of the disease. The authors report 4 cases in which echocardiographic detection of characteristic right ventricular involvement led to the confirmation of the diagnosis of carcinoid tumour leading to the secondary diagnosis of the primary carcinoid tumour. The clinical, physiopathological echocardiographic and therapeutic characteristics of this condition are discussed.

Successful balloon dilatation of the pulmonary valve in carcinoid heart disease

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.

Balloon dilation of tricuspid and pulmonary valves in carcinoid heart disease

Heart involvement is usually the cause of death in patients with carcinoid syndrome, who may survive a long time even after the disease has entered an advanced stage. For this reason, carcinoid heart disease patients have undergone surgical replacement of affected valves. Two of our patients were not good candidates for surgery, due to the extent of hepatic metastasis. Alternatively, we performed percutaneous balloon valvuloplasty on both the tricuspid and pulmonary valves in both patients. To our knowledge, there has been only 1 previous report of successful tricuspid valvuloplasty in a case of carcinoid heart disease, and this did not involve concomitant pulmonary valvuloplasty. Before the procedure, both of our patients had low cardiac output with restriction in the right ventricle, pulmonary and tricuspid stenosis, and moderate tricuspid regurgitation. In the 1st patient, valvuloplasty reduced tricuspid and pulmonary gradients without change in cardiac output. This patient experienced initial clinical improvement but died 8 months after the procedure, of portal hypertension and extensive hepatic metastasis. The 2nd patient showed notably diminished gradients and a very significant increase in cardiac output. She advanced from New York Heart Association functional class IV to class I, and is now maintained with diuretic therapy. In our judgment, balloon valvuloplasty is a sound alternative to surgery for patients with carcinoid heart disease, especially when stenosis is the dominant symptom. Valvuloplasty is contraindicated in cases of severe tricuspid regurgitation.

[Tricuspid and pulmonary percutaneous valvulopathy in the cardiopathy of the carcinoid syndrome. A case report]

We present a 36-year-old woman with a malignant carcinoid syndrome, liver metastases and right heart involvement with severe tricuspid and pulmonic valve stenosis. She was admitted with severe heart failure and poor general status. A combined tricuspid and pulmonic valvuloplasty was performed and she exhibited great clinical improvement that was maintained during the follow-up. We point out the importance of two-dimensional echocardiography in the diagnosis of this pathology and the role of Doppler measurements for the evaluation of the valvuloplasty's results.

Carcinoid heart disease: report of a case secondary to a pure carcinoid tumour of the ovary

Carcinoid heart disease secondary to ovarian carcinoid is a rare finding, with only 12 cases reported in the literature to date. Most ovarian carcinoids arise from ovarian cysts or teratomata, the 'pure' carcinoid being exceedingly rare. We present a case of carcinoid syndrome with tricuspid valve involvement in a patient with 'pure' ovarian carcinoid.