『Carcinoid Heart Disease: Ready for the Ventricle』のカバーアート

Carcinoid Heart Disease: Ready for the Ventricle

Carcinoid Heart Disease: Ready for the Ventricle

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概要
 In carcinoid syndrome, you must never give adrenaline. Most of us were taught that — but it comes from decades-old experiments in end-stage patients who had never been near octreotide. So does the rule still stand? This episode is carcinoid heart disease, from the tumour to intensive care. We start with neuroendocrine tumours and carcinoid syndrome, why the syndrome usually needs liver metastases, and why serotonin damages the tricuspid and pulmonary valves while the left heart is usually spared — and what it means when it isn't. Then the echo picture, why this disease progresses so much faster than other right-sided valve disease, how patients are screened and followed up, and what medical therapy can and can't do. Then surgery: who should have it, why the cancer has to be under control first, the risk factors (including a deceptively low creatinine in sarcopenic patients), and the nutritional problems that come with the disease. We spend time on the right ventricle that looks fine with free tricuspid regurgitation and then fails once the valve works, and on how stress right heart catheterisation can help predict it. In theatre: octreotide and what it really does, whether catecholamines are as dangerous as we were taught, what a carcinoid crisis looks like under the drapes, and the limited role of mechanical support. Then intensive care — the right ventricle, acute kidney injury, mesenteric ischaemia, heart block and how to avoid it — and where the field is heading, from transcatheter valves to liver transplantation. We finish with a handover to the night team: everything you need to know about a carcinoid valve patient on day one. Chapters (00:00) Cold open — never give adrenaline?(01:05) Neuroendocrine tumours and carcinoid syndrome(02:40) What carcinoid heart disease is — and why it's right-sided(03:50) The echo picture and how fast it progresses(04:35) Screening and follow-up(05:15) Medical treatment(06:10) Nutrition and frailty(07:00) Who should have surgery(07:55) The right ventricle problem(09:00) Preoperative assessment(10:00) Octreotide(10:50) Catecholamines: is adrenaline really forbidden?(11:45) Carcinoid crisis(13:00) Mechanical support(13:35) The anaesthetic(14:05) Intensive care: kidneys, gut and heart block(16:10) Where the field is heading(16:40) The handover Key takeaways Carcinoid syndrome usually needs liver metastases: their secretions bypass hepatic breakdown and reach the systemic circulationCarcinoid heart disease is a paraneoplastic effect of serotonin and other mediators, not tumour in the heart — leaflets thicken, retract and fix openIt is classically tricuspid and pulmonary; left-sided involvement should prompt a search for a shunt, lung metastases or an ovarian primary — or other valve diseaseIt progresses quickly; screen with NT-proBNP and echo, never discharge from follow-up, and refer before the right ventricle failsMedical therapy controls the syndrome and the fluid, but cannot reverse valve damage; big diuretic doses are common, before and after surgeryMalnutrition, niacin and vitamin D deficiency and pancreatic insufficiency are common; weight can hide muscle loss behind oedemaOperate only when the cancer is controlled; age over 70, frailty, renal impairment and complexity raise the riskFree TR unloads the right ventricle — a competent valve can unmask failure; stress right heart catheterisation helps but isn't foolproofCheck for a PFO with a bubble study: it should be closed, and right-to-left shunting can cause hypoxia at inductionWith octreotide on board, catecholamines don't appear to worsen outcomes; a small dilute adrenaline test dose is one cautious approachCarcinoid crisis behaves like distributive shock: octreotide, fluid and early vasopressorsWatch for AKI, mesenteric ischaemia and heart block; extubate early, use depth-of-anaesthesia monitoring, and mobilise and feed early References / further reading Davar J, Connolly HM, Caplin ME, et al. Diagnosing and managing carcinoid heart disease in patients with neuroendocrine tumors: an expert statement. J Am Coll Cardiol 2017; 69: 1288–304Grozinsky-Glasberg S, Davar J, Hofland J, et al. European Neuroendocrine Tumor Society (ENETS) 2022 guidance paper for carcinoid syndrome and carcinoid heart disease. J Neuroendocrinol 2022; 34: e13146Connolly HM, Schaff HV, Abel MD, et al. Early and late outcomes of surgical treatment in carcinoid heart disease. J Am Coll Cardiol 2015; 66: 2189–96Condron ME, Pommier SJ, Pommier RF. Continuous infusion of octreotide combined with perioperative octreotide bolus does not prevent intraoperative carcinoid crisis. Surgery 2016; 159: 358–65 Follow the podcast Bluesky: @cardiacoutput.bsky.social X: @CardiacOutputMC If you've found this useful, a follow or a share genuinely helps other trainees find it — and do get in touch if there's a topic you'd like covered. This podcast is for medical education for healthcare professionals. It is not ...
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