Endocrine Abstracts

The treatment of patients with carcinoid heart disease (CHD) presents substantial challenges due to the advanced multisystem nature of their disease. Intensive multidisciplinary collaboration and innovative techniques are often required in order to manage these patients. Here we describe two such cases from our institution. A 59-year old gentleman with metastatic NET and CHD was referred to our centre. Transoesophageal echocardiography demonstrated severe tricuspid regurgitation and a patent foramen ovale (PFO) with left to right flow. During induction of anaesthesia for valve replacement surgery he became severely hypotensive and hypoxemic, consistent with a carcinoid crisis. Surgery was abandoned and he was transferred to the intensive care unit where he remained persistently hypoxemic. Bubble echocardiography demonstrated shunt reversal with right to left flow across the PFO. He underwent percutaneous PFO closure under local anaesthesia guided by intra-cardiac echocardiography (ICE) which led to rapid resolution of hypoxaemia. He recovered well and underwent successful tricuspid and pulmonary valve replacement surgery 3 months later. The second patient was a 69 year old male with CHD who underwent tricuspid and pulmonary valve replacements. Twelve hours post operatively he developed episodes of unprovoked hypotension and bronchospasm consistent with carcinoid crisis. After initially responding to octreotide he went into cardiac arrest. Following emergency resternotomy in the ICU he was placed on peripheral VA ECMO. Treatment for his carcinoid crises was maximised and on day 10, whilst on ECMO he underwent selective hepatic artery embolization of his liver metastasis in an attempt to further reduce his tumour burden. On day 17 post op he developed worsening biventricular dysfunction during an attempted ECMO wean. Following MDT discussion, and with his family’s agreement, treatment was withdrawn and he died on post op day 18. These cases illustrate some of the novel techniques that can be used to aid the management of patients in extremis with carcinoid heart disease. Due to the relatively low numbers of cases, a further collaboration is required amongst centres of excellence and it calls for an international registry to be developed to improve care in this patient group.