BJA Advance Access published online on August 8, 2008
British Journal of Anaesthesia, doi:10.1093/bja/aen237
Management of patients undergoing multivalvular surgery for carcinoid heart disease: the role of the anaesthetist
1 Department of Cardiothoracic Surgery, Mount Sinai Medical Center, 1190 Fifth Avenue, Box 1028, New York, NY 10029, USA
2 Department of Anesthesia, Mount Sinai Medical Center, One Gustave L. Levy Place, Box 1010, New York, NY 10029, USA
* Corresponding author. E-mail: javier.castillo{at}mountsinai.org
Background: The management of patients with carcinoid heart disease poses two major challenges for the anaesthetist: carcinoid crisis and low cardiac output secondary to right ventricular (RV) failure. Carcinoid crises may be precipitated by the administration of catecholamines and histamine-releasing drugs.
Methods: We analysed a series of 11 patients [six males, median (range) age 60 (42–73) yr] with severe symptomatic carcinoid heart disease who underwent multivalve surgery (right-sided valves, n=8; right- and left-sided valves, n=3) between 2001 and 2007.
Results: All patients received octreotide intraoperatively [650 (300–1050) µg] to prevent carcinoid symptoms and vasoplegia. Those patients on a greater preoperative octreotide regime required additional intraoperative octreotide [median (range) dose 320 (300–850) vs 750 (650–1050) µg]. Similarly, the use of greater doses of aprotinin (>5 KIU) was associated with greater requirements for octreotide [475 (300–700) vs 750 (320–1050) µg] and higher glucose levels (
8.5 mmol litre–1). Catecholamines were generally required in those patients who presented with a worse New York Heart Association functional class. Overall mortality was 18% (n=2) and only one episode of mild intraoperative carcinoid crisis was observed.
Conclusions: Carcinoid crisis and RV failure still remain the primary challenges for the anaesthesiologist while managing patients with carcinoid heart disease. Our study supports the administration of catecholamines to wean patients off cardiopulmonary bypass, particularly in the presence of myocardial dysfunction. Those patients on higher octreotide dosages may require close intraoperative glucose monitoring. Despite high operative mortality, surgical outcome has been improved potentially due to earlier patient referral and better perioperative management.
Keywords: complications, carcinoid syndrome; pharmacology, 5-HT antagonists; surgery, cardiovascular