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Percutaneous closure of a patent foramen ovale in left-sided carcinoid heart disease Paru R Chaudhari, Jeffrey Abergel, Richard R Warner, Jerome Zacks, Barry A Love, Jonathan L Halperin and Eric Adler* Vanderbilt Continuing Medical Education online
SUMMA RY
This article offers the opportunity to earn one Category 1
Background A 51-year-old woman with a 5-year history of metastatic
credit toward the AMA Physician’s Recognition Award.
small bowel carcinoid disease developed fatigue and gradually worsening dyspnea on exertion, over 6 months. Investigations Physical examination, transthoracic and transesophageal echocardiography, and aortography. Diagnosis Left-sided carcinoid disease associated with a patent foramen ovale. Management Percutaneous transcatheter closure of the patent foramen ovale.
THE CASE
Keywords carcinoid syndrome, left-sided heart disease, patent foramen ovale, percutaneous closure, valvular heart disease
cme
PR Chaudhari is a fourth-year medical student, J Abergel is a House Officer, RR Warner is Clinical Professor of Medicine and Gastroenterology, J Zacks is Assistant Clinical Professor of Medicine and Cardiology, BA Love is Director of the Congenital Cardiac Catheterization Laboratory, JL Halperin is the Robert and Harriet Heilbrunn Professor of Medicine at the Zena and Michael A Wiener Cardiovascular Institute and Center for Cardiovascular Health, and E Adler is an Instructor of Medicine, at Mount Sinai School of Medicine, New York, NY, USA. Correspondence *Department of Internal Medicine, Mount Sinai School of Medicine, One Gustave Levy Place, New York, NY 10029, USA
[email protected] Received 4 October 2006 Accepted 30 March 2007 www.nature.com/clinicalpractice doi:10.1038/ncpcardio0944
august 2007 vol 4 no 8
A 46-year-old female with no previously documented illnesses presented with 15 months of diarrhea, abdominal pain, and flushing after alcohol consumption. Abdominal CT showed multiple hepatic masses, and needle biopsy yielded tissue consistent with a neuroendocrine tumor of the carcinoid type. Octreotide imaging localized the primary tumor to the terminal ileum of the small intestine. Transthoracic echocardiography at that time showed no tricuspid or pulmonic valve thickening. The estimated right atrial pressure was 10 mmHg and estimated right ventricular systolic pressure was 26 mmHg. The patient underwent ileocolic resection followed by treatment with octreotide, adriamycin, gemcitabine and oxaliplatin, and yttrium-90 microsphere radioembolization of the hepatic metastases. Five years later, she reported fatigue and gradually worsening dyspnea on exertion, over 6 months, accompanied by bilateral leg swelling, over 2 months. Physical examination showed normal breath sounds, no clubbing, a grade II/VI systolic murmur loudest at the left and right upper sternal borders, and 2 + pitting edema to both knees. While breathing room air, the arterial pH was 7.48, Pco2 was 34 mmHg, and Po2 was 59 mmHg, and bedside oxygen saturation was 85% while standing and 91% while supine. Hemodynamic data are summarized in Table 1. Transthoracic echocardiography showed a dilated right ventricle, thickening and mildly restricted movement of the tricuspid valve leaflets, 2 + insufficiency of the tricuspid, pulmonic and mitral valves, and an estimated right ventricular systolic pressure of 39 mmHg. Following intravenous injection of agitated saline, brisk rightto-left interatrial shunting was demonstrated, consistent with a patent foramen ovale (PFO).
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Table 1 Summary of the patient’s hemodynamic data at presentation. Location
Blood pressure (mmHg)
Normal values (mmHg)
Right atrium
5
