Journal: Br J Anaesth 101(5):618-626, 2008. 33 References
Reprint: Dept of Cardiothoracic Surgery, Mount Sinai Medical Center, 1190 Fifth Avenue, Box 1028, New York, NY 10029 (JG Castillo, MD)
Faculty Disclosure: Abstracted by S. Ouellette, who has nothing to disclose.
Carcinoid tumors are rare, slow growing tumors derived from enterochromaffin cells that make up the amine precursor and decarboxylation (APUD) system. They are most commonly located in the gastrointestinal tract and the bronchopulmonary system. The incidence of carcinoid tumors ranges from 3 to 4 per 100,000 yr in the USA. At the time of diagnosis, 20 to 30% of patients present with disseminated disease and consequent malignant carcinoid syndrome defined by cutaneous flushing (90%), gastrointestinal hypermotility (70%), heart involvement (30%), and bronchospasm (15%). The term carcinoid heart disease is used to describe the severe fibrotic endocardial plaquing resulting from elevated 5-hydroxytryptamine (serotonin), histamine, tachykinins, prostaglandins, and possibly other growth factors released from the tumor. Structural changes in cardiac valves leading to dysfunction occur in more than 50% of patients with secondary hepatic metastases. Valve damage generally involves right sided valves.
Carcinoid heart disease poses two challenges to the anesthetist: carcinoid crisis and low cardiac output syndrome secondary to right ventricular failure. Carcinoid crisis, characterized by flushing, hypotension, and bronchospasm, may be precipitated by administration of catecholamines and histamine-releasing drugs administered during anesthesia. Although the somatostatin analogue octreotide stabilizes hemodynamic variables, it is challenging to differentiate between hypotension due to carcinoid crisis as opposed to low cardiac output syndrome secondary to myocardial dysfunction. The purpose of this report was to discuss operative experience and management of 11 patients with carcinoid heart disease who underwent multivalvular surgery. |
