EComment. Valve replacement in carcinoid heart disease

Abstract

We read with great interest the paper by Mabvuure et al. regarding the durability of bioprostheses in patients with carcinoid valve disease [1]. Carcinoid heart disease occurs in the context of metastatic serotonin-producing neuroendocrine tumours in the liver and classically presents as a progressive dysfunction of the tricuspid and/or pulmonary valve due to endocardial plaque deposition, thus reducing the mobility of the right-sided valve leaflets [2]. Surgical valve replacement is the only effective treatment when symptoms of right heart failure emerge in this patient population. Mabvuure and colleagues included the results of 17 papers in their research, and the pooled data represented 51 patients with bioprostheses in the tricuspid position [1]. Recently, an additional retrospective study was published [3] and the purpose of this study was to assess the early and late outcomes of patients with carcinoid heart disease after valve replacement. In the above-mentioned study, three patients received one or two bioprostheses. However the remaining 16 patients underwent implantation of mechanical valve prostheses. Early postoperative mortality was 10% and survival rates at 1 and 5 years were 71 and 43% respectively. At the last follow-up, all survivors were in NYHA class I and echocardiography showed improvement of right ventricle function in the majority of patients. Although we recognize the efforts of Mabvuure and colleagues to identify the durability of biological valve in patients with carcinoid heart disease undergoing valve replacement by reviewing the relevant literature, we would like to point out an important point that they failed to include in their report. Classically, severe tricuspid regurgitation coexists with pulmonary valve stenosis in patients with symptomatic carcinoid valve disease. The simple surgical management consists in a tricuspid replacement in combination with pulmonary valvectomy. This will leave the patient with some degree of pulmonary incompetence while implanting one prosthetic valve. For patients with combined pulmonary and tricuspid stenosis, percutaneous balloon valvuloplasty is a feasible and effective alternative in cases with severe comorbidity or frailty [4]. In conclusion, surgeons should not hesitate to implant bioprostheses in this patient population. Accumulating data supporting the very low incidence of premature tissue valve degeneration in patients with carcinoid heart disease should be taken into consideration. Nevertheless, in patients where the carcinoid tumor is well-controlled and long-lasting survival is anticipated, a mechanical prosthesis may be implanted to avoid the possibility of carcinoid plaquing of the biological valve. However, in the setting of serious liver metastases, the use of a bioprosthesis could still be a better alternative. Conflict of interest: none declared.