title: Management of patients undergoing multivalvular surgery for carcinoid heart disease: the role of the anaesthetist.
abstract: BACKGROUND
  The management of patients with carcinoid heart disease poses two major challenges for the anaesthetist: carcinoid crisis and low cardiac output secondary to right ventricular (RV) failure. Carcinoid crises may be precipitated by the administration of catecholamines and histamine-releasing drugs.
  
  
  METHODS
  We analysed a series of 11 patients [six males, median (range) age 60 (42-73) yr] with severe symptomatic carcinoid heart disease who underwent multivalve surgery (right-sided valves, n=8; right- and left-sided valves, n=3) between 2001 and 2007.
  
  
  RESULTS
  All patients received octreotide intraoperatively [650 (300-1050) microg] to prevent carcinoid symptoms and vasoplegia. Those patients on a greater preoperative octreotide regime required additional intraoperative octreotide [median (range) dose 320 (300-850) vs 750 (650-1050) mug]. Similarly, the use of greater doses of aprotinin (> 5 KIU) was associated with greater requirements for octreotide [475 (300-700) vs 750 (320-1050) microg] and higher glucose levels (> or =8.5 mmol litre(-1)). Catecholamines were generally required in those patients who presented with a worse New York Heart Association functional class. Overall mortality was 18% (n=2) and only one episode of mild intraoperative carcinoid crisis was observed.
  
  
  CONCLUSIONS
  Carcinoid crisis and RV failure still remain the primary challenges for the anaesthesiologist while managing patients with carcinoid heart disease. Our study supports the administration of catecholamines to wean patients off cardiopulmonary bypass, particularly in the presence of myocardial dysfunction. Those patients on higher octreotide dosages may require close intraoperative glucose monitoring. Despite high operative mortality, surgical outcome has been improved potentially due to earlier patient referral and better perioperative management.
authors.affiliation: Department of Cardiothoracic Surgery, Mount Sinai Medical Center, 1190 Fifth Avenue, Box 1028, New York, NY 10029, USA. javier.castillo@mountsinai.org
authors.forename: J G
authors.initials: JG
authors.lastname: Castillo
authors.forename: F
authors.initials: F
authors.lastname: Filsoufi
authors.forename: D H
authors.initials: DH
authors.lastname: Adams
authors.forename: J
authors.initials: J
authors.lastname: Raikhelkar
authors.forename: B
authors.initials: B
authors.lastname: Zaku
authors.forename: G W
authors.initials: GW
authors.lastname: Fischer
mesh_terms: D000328:Adult; D000368:Aged; D000768:Anesthesia, General / Q000379:methods*; D018931:Antineoplastic Agents, Hormonal / Q000627:therapeutic use; D007611:Aprotinin / Q000627:therapeutic use; D002275:Carcinoid Heart Disease / Q000150:complications / Q000000981:diagnostic imaging / Q000188:drug therapy / Q000601:surgery*; D002315:Cardiopulmonary Bypass; D015150:Echocardiography, Doppler / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006349:Heart Valve Diseases / Q000000981:diagnostic imaging / Q000601:surgery*; D006490:Hemostatics / Q000627:therapeutic use; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D007431:Intraoperative Complications / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D015282:Octreotide / Q000627:therapeutic use; D012189:Retrospective Studies; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000627:therapeutic use; D018497:Ventricular Dysfunction, Right / Q000517:prevention & control
chemical_list: D018931:Antineoplastic Agents, Hormonal; D006490:Hemostatics; D014662:Vasoconstrictor Agents; D007611:Aprotinin; D015282:Octreotide