Internal Medicine Resident HOUSTON, Texas, United States
Disclosure(s):
Fatima Iqbal, MD: No financial relationships to disclose
Background: Carcinoid heart disease is a rare complication of neuroendocrine tumors (NETs), and left untreated, has high rates of morbidity and mortality.
Methods:
Case Presentation: A 77-year-old female with a past medical history of metastatic neuroendocrine tumor and stage III chronic kidney disease was initially admitted for hypotension in the setting of poor oral intake. Initial vitals were notable for heart rate 118 bpm, blood pressure 99/75 mmHg, respiratory rate 20 breaths/min and SpO2 96% on room air. Physical exam was remarkable for lethargy and cold, edematous extremities. Labs were notable for lactic acidosis to 4.7 mmol/L, NT-Pro BNP elevation to 15,900 pg/ml and liver injury with ALT 203 U/L and AST 677 U/L. Transthoracic echocardiogram showed moderate right ventricular dilation, severe tricuspid regurgitation, with systolic flow reversal in hepatic veins, and moderate-severe pulmonic insufficiency, representing right-sided carcinoid heart disease. Right heart catheterization subsequently revealed severely reduced Fick’s CI of 1.1 L/min/m2, CO of 2.19 L/min and the following pressures: RA 14/27/19 mmHg, RV 28/8/6 mmHg, PA 28/23/25 mmHg and PCWP 13 mmHg. Given presentation of right ventricular failure and cardiogenic shock (CS), dobutamine drip was started for inotropic support, but was poorly tolerated due to hypotension and was switched to dopamine. Continuous renal replacement therapy (CRRT), when diuresis was not achieved for preload reduction, was initiated.
Outcome: The patient continued to decompensate and was not a candidate for surgical valvular interventions, due to significant frailty and advanced kidney disease, or for mechanical circulatory support. She ultimately suffered pulseless electrical activity (PEA) arrest leading to death.
Conclusion: Our case highlights the need for high suspicion of carcinoid heart disease, in patients with known NETs, to prevent progression to decompensated valvular heart disease and CS and allow for timely valvular interventions.
