Transcatheter Pulmonic Valve-in-Homograft Replacement in a Patient with Carcinoid Heart Disease
Presenter
Rahul Sawhney, DO, Baylor Scott & White The Heart Hospital - Plano, Plano, TX
Rahul Sawhney, DO1, Amr Idris, MD1, Jared L Christensen, MD1, Alex T Cubberley, MD2, Clarence Findley, M.D., Ph.D., FSCAI1, Zuyue Wang, MD1, Katherine Brooks Harrington, M.D.1, Srini Potluri, M.D., FSCAI3 and Molly Szerlip, M.D., FSCAI4, (1)Baylor Scott & White The Heart Hospital - Plano, Plano, TX, (2)Drexel University College of Medicine, Philadelphia, TX, (3)Baylor Scott & White The Heart Hospital - Plano, Frisco, TX, (4)Baylor Scott & White The Heart Hospital - Plano, Richardson, TX
Title
Transcatheter Pulmonic Valve-in-Homograft Replacement in a Patient with Carcinoid Heart Disease
Introduction
Carcinoid heart disease is present in 50-70% of patients with carcinoid tumors. Excess serotonin exposure results in negative remodeling of the tricuspid valve and pulmonic root leading to regurgitation or stenosis. Classically these patients are young, and thus the long-term implications of surgical valve replacement must be considered. Herein we report the case of a 55-year-old man with severe stenosis of a pulmonic valve homograft who underwent transcatheter valve intervention with a 29 mm SAPIEN S3 (Edwards Lifesciences) bioprosthesis deployed in the pulmonic position.
Clinical Case
A 55-year-old white man with history of carcinoid syndrome on octreotide therapy, carcinoid heart disease status post tricuspid/pulmonic valve replacement, essential hypertension, hypothyroidism, and complete heart block status post permanent pacemaker implantation presented to our valve clinic with complaints of 3-6 months of decreased exercise tolerance. 5 years earlier, his tricuspid and pulmonic valves were replaced secondary to severe regurgitation. Transthoracic echocardiogram demonstrated marked dilatation of the right atrium/ventricle, preserved left ventricular function, severe stenosis of the 30 mm pulmonic homograft with mild regurgitation (peak velocity 4.5 m/s, velocity time integral 131 cm, mean gradient 39 mmHg), and normal function of the 31 mm bioprosthetic tricuspid valve with mean gradient of 4 mmHg. Computed tomography (CT) redemonstrated severe pulmonic stenosis with a valve area of 0.86 cm^2. Surgical valve replacement was considered. However, due to his short interval since last sternotomy, underlying carcinoid syndrome, and working tricuspid valve replacement our heart team elected to perform transcatheter replacement. He underwent serial dilation of the pulmonic valve homograft from 11 to 28 mm, insertion of a 4.5 cm, 8 Zig, covered CP stent (Braun Interventional Systems), and deployment of a 29 mm SAPIEN S3 valve in the pulmonic position. The stent and valve were delivered through a 65 cm Gore DrySeal hydrophilic introducer sheath (W. L. Gore & Associates). The pulmonic valve gradient and peak velocity decreased to 7 mmHg and 1.84 m/s, respectively. There was no perivalvular leak. Repeat CT heart showed iatrogenic pulmonic root rupture which was contained with the covered stent. No damage to the tricuspid bioprosthesis was noted. The patient was discharged home in good condition on post-intervention day 1. At the 2-week mark, he reported an improvement in exertional dyspnea and denied any appreciable complications.
Discussion
Percutaneous pulmonic valve replacement is being performed with increasing frequency as more data emerges on its safety and efficacy. Special attention needs to be paid to the tricuspid valve to avoid iatrogenic injury during pulmonic valve intervention. In our case, we avoided tricuspid valve damage by using a long, large-caliber, hydrophilic introducer sheath. We also pre-stented with a covered stent to contain iatrogenic pulmonic root rupture and provide a scaffold for the transcatheter valve. Further study is still necessary as the target population of patients with congenital or right-sided valvular disease continues to grow. The heart team approach will continue to play an integral role in the evaluation and management of such patients.