Early Carcinoid Robotic Tricuspid Bioprosthesis Destruction: A case for a mechanical prosthesis
Barbara L. Robinson1, Randolph Chitwood2
1East Carolina Heart Institute, Lake Barrington, IL, USA, 2East Carolina Heart Institute, Greenville, NC, USA
OBJECTIVE: Carcinoid valvular heart disease is challenging with effects of serotonin contributing to valvular degeneration, eventuating in severe insufficiency(TR) or stenosis(TS), both indications for TVR. With persistent hepatic carcinoid disease, cardiac operation is performed first to reduce the CVP, optimizing subsequent hepatic intervention. We report a case of rapid TVR pericardial prosthesis degeneration due to severe carcinoid disease.
METHODS: A 45-year-old gentleman, had a primary terminal ileal carcinoid, hepatic metastases, and elevated chromograningranin, s/p chemotherapy presented with dyspnea, a pansystolic murmur, JVD, hepatomegaly, ascites, and peripheral edema and massive TR(Figure1A).
Initially, with the possibility of future hepatic interventions, he did not desire a mechanical prosthesis. He underwent a robot-assisted TVR with a #29 bovine pericardial prosthesis.
RESULTS: Nine months later, he developed severe bioprosthetic TR with TS (Figure 1B). At the second operation the immobile, retracted bioprosthetic pericardial valve leaflets were encased in carcinoid fibrotic plaque and curled outward toward the ventricle. Annular tissue was also fibrotic. Papillary muscles were foreshortened and adherent to the under surface of the bioprosthesis and right ventricle with thickened, fused and shortened chordae tendenae (Figure1C). The destroyed bioprosthesis(Figure1D) was exceedingly difficult to extirpate and was replaced via median sternotomy with a 27-mm St.Jude mechanical prosthesis.
CONCLUSIONS: Re-operating for bioprosthesis destruction is difficult because of the carcinoid sclerotic tissue incorporation. Patients having severe well controlled symptomatic valvular carcinoid disease who can tolerate anticoagulation, may undergo a more durable tricuspid mechanical prosthesis which seems prudent at the initial TVR for both the patient and surgeon.
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