Severe tricuspid regurgitation (TR) leads to a reduction in cardiac output and an increase in the central venous pressure, resulting in secondary organ dysfunction. Surgery for severe TR is a high-risk procedure, particularly in the presence of uncontrolled carcinoid syndrome (CS) symptoms. Replacement of leaking tricuspid valves can lead to reduction in tumour markers and improvement in carcinoid symptoms. Transcatheter valve implantation into the vena cava may be an alternative treatment for reducing the complications and symptoms associated with TR.
We report a case of a 69-year-old female with severe CS and severe carcinoid heart disease (CHD) affecting daily activities despite being on a somatostatin analogue (SSA). Uncontrolled CS symptoms deemed her too high risk for open-heart surgery. She had only 30% liver replacement by tumour and good liver function. She was deemed to have a good prognosis provided she could undergo heart valve replacement followed by transarterial embolisation (TAE) of the liver metastases. We planned a percutaneous approach to control the effects of tricuspid regurgitation on the liver to enable transarterial embolisation of liver metastases to be performed. Adequate control of CS would then allow heart surgery to be performed safely.
An octreotide infusion was commenced pre-procedure and continued post-procedure. Two stents were implanted into the IVC and SVC. A 29 mm S3 valve was then deployed within the IVC stent. Prior to valve deployment, phasic pressure in the IVC was 32/20 mmHg with a mean of 22 mmHg. Following valve deployment, the IVC pressure fell to 15/8 mmHg with a mean of 15 mmHg, and venography confirmed only minor paravalvular regurgitation. The procedure was well tolerated throughout. Unfortunately, following the procedure, the patient became very unstable and despite very high doses of SSAs, she passed away as a result of severe carcinoid crisis.
IVC valve implantation specifically to improve CS has not been attempted before. Sadly, this novel approach to managing severe tricuspid regurgitation and carcinoid syndrome was unsuccessful in this case. Further work is needed to devise successful strategies for managing this difficult but potentially salvageable group of patients.
05 Dec 2016
UK and Ireland Neuroendocrine Tumour Society