Effect of valvular surgery in carcinoid heart disease: An observational cohort study

Abstract

Context: Carcinoid heart disease (NET-CHD) is associated with the development of symptom-limited exercise capacity and high rates of morbidity and mortality. Objective: This study sought to determine the survival, cardiac function, and functional class following surgery. Design and Setting, and Patients: This was a retrospective observational cohort study between 2005 and 2015 at a European Centre of Excellence for Neuroendocrine Tumours, Queen Elizabeth Hospital Birmingham. England consisting of 62 consecutive patients referred to the NET-Cardiology Service. Interventions: Subjects were assessed at referral using transthoracic echocardiography (with saline contrast) and transesophageal echocardiography, and 77% with confirmed NET-CHD underwent cardiovascular magnetic resonance imaging. Symptomatic patients with concomitant severe valvular dysfunction were referred for surgery with stable NET disease. Main Outcome Measure: Survival of patients with proven NET-CHD following medical and surgical treatments was measure. Results: In total, 47/62 patients were diagnosed with NET-CHD. Thirty-two patients (68%) underwent surgery with bioprosthetic valve replacements in all subjects; tricuspid, n = 31; pulmonary, n=30; mitral,n=3;andaortic,n=3. Four patients underwent concomitant coronary artery bypass grafting. There were 4 (13%) early post-operative deaths. One- and 2-y survival rates after surgery were 75 and69%compared with 45 and15%in un-operated patients. Post-operatively, functional class was improved (preâ€"New York Heart Association Classification [NYHA], 2.6 [0.5] vs post-NYHA, 1.7 [1.1]), P = .05, right-ventricular (RV) size was reduced (136 ml/m2 [25] vs 71 ml/m2 [7]; P = .01) with preserved RV ejection fraction (61% ± 9 vs 55%± 10; P = .26). Conclusion: Valve surgery improved functional class and resulted in RV reverse remodelling with improved survival rates at 2 y compared with those not proceeding to operation. These data highlight the importance of close collaboration between NET clinicians, cardiology, and cardiothoracic surgery teams. Early referral can improve functional capacity but more research is needed to define the selection of appropriate candidates and randomized data are needed to define the effect of surgery on prognosis.