Ann Thorac Surg 2009;87:321. doi:10.1016/j.athoracsur.2008.04.061
© 2009 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Early Bioprosthetic Valve Deterioration After Carcinoid Plaque Deposition
Javier G. Castillo, MDa,
Farzan Filsoufi, MDa,
Parwis B. Rahmanian, MDa,
Jerome S. Zacks, MDb,
Richard R.P. Warner, MDc,
David H. Adams, MDa,*
a Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, New York
b Department of Clinical Cardiology, Mount Sinai School of Medicine, New York, New York
c Division of Gastroenterology, Mount Sinai School of Medicine, New York, New York
* Address correspondence to Dr Adams, Department of Cardiothoracic Surgery, Mount Sinai Medical Center, 1190 Fifth Ave, Box 1028, New York, NY 10029 (Email: david.adams{at}mountsinai.org).
A 47-year-old man with carcinoid heart disease underwent tricuspid and pulmonary bioprosthetic valve replacement, as well as mitral and aortic valve repair. Following this procedure, the patient underwent resection of the primary carcinoid tumor located in the mid-ileum and concomitant left liver lobectomy. Within 25 months, both bioprostheses developed structural valve deterioration with mixed regurgitation and stenosis.
The patient underwent an uneventful reoperative mechanical tricuspid (Fig 1A) and pulmonary (Fig 1B) valve replacement. Gross pathology showed thickened, rubbery and nonpliable leaflets with whitish plaque deposition of carcinoid-like tissue. Histopathology of both bioprostheses confirmed an exuberant inflow and outflow fibrocellullar pannus growth of recurrent carcinoid plaque deposition at the level of the sewing ring and pericardial leaflets. Microscopic analysis did not reveal direct infiltration of the pericardial leaflet by carcinoid tissue (Fig 2A), but rather the deposition of carcinoid plaque characterized by a collection of myofibroblast and an extracellular component consisting of collagen and myxoid matrix (Fig 2B; Hematoxylin and eosin; x200 original magnification).
Carcinoid heart disease is rare and most commonly involves the right-sided valves resulting in severe leaflet fibrosis and retraction, mandating surgical replacement. In patients with carcinoid heart disease undergoing valvular replacement, the choice of valvular prosthesis remains controversial. Early structural valve deterioration due to vasoactive substances has been described, and the relatively young age of these patients is another consideration [1–3]. Nonetheless, we favor bioprostheses in our carcinoid patients because almost all of them require additional abdominal surgical procedures for tumor control, which complicates anticoagulation therapy. In this particular patient, a high tumoral activity (5-HIAA 432 mg/24 hr, serotonin, 616 ng/mL), despite maximal medical therapy, may have lead to early structural valve deterioration and was the reason we choose to perform mechanical valve re-replacements.
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References
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- Ridker PM, Chertow GM, Karlson EW, Neish AS, Schoen FJ. Bioprosthetic tricuspid valve stenosis associated with extensive plaque deposition in carcinoid heart disease Am Heart J 1991;121:1835-1838.[Medline]
- Schoen FJ, Hausner RJ, Howell JF, Beazley HL, Titus JL. Porcine heterograft valve replacement in carcinoid heart disease J Thorac Cardiovasc Surg 1981;81:100-105.[Abstract]
- Ohri SK, Schofield JB, Hodgson H, Oakley CM, Keogh BE. Carcinoid heart disease: early failure of an allograft valve replacement Ann Thorac Surg 1994;58:1161-1163.[Abstract/Free Full Text]
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