Dr. Kornfield presented a very interesting case of a patient referred to pulmonary clinic with shortness of breath, presumed to be related to undiagnosed COPD.
A 68 year-old veteran with a history of tobacco use and metastatic carcinoid presented with one year of progressively worsening dyspnea on exertion, such that he could only walk ~50 feet before resting. He denied any significant cough or sputum production and had no benefit from use of a bronchodilator. He noted lower extremity edema without orthopnea or paroxysmal nocturnal dyspnea. On exam, JVP was estimated at 12 cm H20 and a new, soft systolic murmur was noted. A TTE revealed thickened tricuspid valve leaflets, severe TR, RVSP upper limit of normal, and EF 60-65% EF. He was diagnosed with carcinoid heart disease (!) and referred for consideration of valve replacement surgery.
Carcinoid heart disease is a rare manifestation of advanced carcinoid tumors typically involving right heart valves (most commonly the tricuspid valve), and resulting in right heart failure.
There is a 20% prevalence of cardiac involvement in patients with carcinoid syndrome.
TAKE HOME POINTS
•DDx for dyspnea on exertion is always broad but should include RV failure.
•Suspect carcinoid heart disease in patients with carcinoid tumors and symptoms suggestive of right heart failure. Confirm with echocardiography.
•While multiple medical therapies are available to treat carcinoid, surgery is the effective intervention for valvular disease.