title: Valve Replacement in Patients with Carcinoid Heart Disease: Choosing the Right Valve at the Right Time.
abstract: The prosthetic valve of choice in patients with carcinoid valve disease (CVD) remains controversial due to the limited life expectancy of patients with advanced-stage neuroendocrine tumors (NETs) on the one hand, and concerns regarding structural valve deterioration (SVD) on the other hand.
  
  
  
  The records of 17 patients (11 females, seven males; mean age 65 ± 11 years; undergoing 18 operations) with primarily right heart failure due to CVD were reviewed. All patients received somatostatin analogs perioperatively. Hospital and follow up data (acquired via direct patient contact and echocardiography) collected included baseline characteristics, procedural details, and clinical outcomes.
  
  
  
  The primary NET site was the ileum (n = 11), lungs (n = 2) and stomach, colon and appendix (n = 1 each). In one patient the primary tumor location could not be identified. Preoperative urinary levels of 5-hydroxyindole acetic acid (5-HIAA; 61 ± 36 mg/24 h) and serum levels of chromogranin A (2926 ± 4057 ng/ml) were 10- and 50-fold greater than normal, respectively. A total of 23 valves was implanted: five tricuspid valve replacements (TVR; four tissue and one mechanical), TVR and pulmonary valve replacements (PVR; three tissue and one mechanical), and TVR and mitral valve replacements (MVR; one tissue and two mechanical). The 30-day mortality was 11% (n = 2). No patient experienced a carcinoid crisis. The mean follow up was 24 ± 21 months (range: 4-85 months). Four patients (receiving seven valves) developed SVD at 12, 14, 15, and 20 months after surgery, and all of these patients died. The actuarial four-year survival and freedom from SVD were 23 ± 14% and 43 ± 15%, respectively.
  
  
  
  The data acquired suggested that the main advantage of tissue valve prostheses, namely to avoid lifelong, intense anticoagulation, might be offset by accelerated SVD. The use of mechanical valves should be considered in CVD patients with a large primary tumor mass and persistent high urinary levels of 5-HIAA, and who are unresponsive to therapy.
authors.affiliation: Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel. Electronic correspondence: akorach@yahoo.com.
authors.forename: Amit
authors.initials: A
authors.lastname: Korach
authors.affiliation: Department of Endocrinology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Simona
authors.initials: S
authors.lastname: Grozinsky-Glasberg
authors.affiliation: Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Joseph
authors.initials: J
authors.lastname: Atlan
authors.affiliation: Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Abeer
authors.initials: A
authors.lastname: Dabah
authors.affiliation: Department of Pathology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Karine
authors.initials: K
authors.lastname: Atlan
authors.affiliation: Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Ehud
authors.initials: E
authors.lastname: Rudis
authors.affiliation: Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Amir
authors.initials: A
authors.lastname: Elami
authors.affiliation: Department of Endocrinology, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: David J
authors.initials: DJ
authors.lastname: Gross
authors.affiliation: Department of Cardiac Surgery, Houston DeBakey Heart and Vascular Institute, Houston, TX, USA.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Reardon
authors.affiliation: Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
authors.forename: Oz M
authors.initials: OM
authors.lastname: Shapira
mesh_terms: D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D002275:Carcinoid Heart Disease / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D006349:Heart Valve Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D006351:Heart Valves / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D006801:Humans; D007557:Israel; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011474:Prosthesis Design; D012189:Retrospective Studies; D012307:Risk Factors; D013781:Texas; D013997:Time Factors; D061665:Time-to-Treatment; D016896:Treatment Outcome
chemical_list: D000925:Anticoagulants