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Advanced carcinoid disease with severe tricuspid and pulmonary regurgitation

Authors: Dr. Julia Grapsa, Dr. Andreas Kalogeropoulos, Dr. Grigorios Karamasis, Mr. Benjamin F Smith, Mr. David Dawson, Prof. Petros Nihoyannopoulos

Hammersmith Hospital
Imperial College NHS Trust

Contact : Julia Grapsa: EACVI ambassador for Greece

On behalf of the EACVI club 35 for Greece


 

Description

63 years old lady with known metastatic carcinoid submitted for follow up echocardiogram

Clinical case information

 

Parasternal long axis view – the left ventricle has normal size while the right ventricle is dilated and volume loaded. The mitral and aortic valves are structurally normal.

Parasternal long axis: measurement of left ventricular dimensions: we measure the wall thickness, the end-diastolic and end-systolic diameter of the left ventricle as well as the left atrial diameter.

Parasternal right ventricular inflow focused on the tricuspid valve. Tthe leaflets are thickened and shortened suggesting carcinoid disease affecting the tricuspid valve. There is also lack of coaptation between the leaflets.

Parasternal short axis of the right ventricular outflow tract: the pulmonary valve is affected by the carcinoid disease and the pulmonary cusps are thickened and shortened. There is severe pulmonary regurgitation with free regurgitant flow.

Apical 4 chamber view. The right ventricle is dilated and volume loaded due to the free flow tricuspid regurgitation. The right atrium is also markedly dilated.

Apical 4 chamber view with colour Doppler. The right ventricle is dilated and volume loaded due to the free flow tricuspid regurgitation. The right atrium is also markedly dilated.

Subcostal view. The inferior vena cava and the hepatic veins are dilated with no respiratory collapse. There is flow reversal (not showed in the hepatic veins indicating severe tricuspid regurgitation. Right atrial pressure is estimated as being greater than 20 mmHg.

 

Apical 4 chamber view : continuous wave Doppler for tricuspid regurgitation: there is free flow regurgitation and as a result low gradient and a steep jet. Bernoulli equation cannot be applied on this occasion.

 

Measurement of the tricuspid annular plane systolic excursion (TAPSE). TAPSE is estimated as 20 mm which is an effect of volume loading secondary to the severe tricuspid regurgitation.

 

 

Tissue Doppler Imaging on the RV free wall: The systolic S wave is measured as 19 cm/sec which represents good overall performance of right ventricular function. However, tissue doppler imaging may be influenced by volume loading.

Real time 3D echocardiography of the tricuspid valve : the view has been obtained from the parasternal right ventricular inflow.

 

Real time 3D echocardiography of the tricuspid valve: the view is obtained from the parasternal right ventricular inflow view and the image is rotated towards the atrial view for a better view of the tricuspid valve: the leaflets are restricted in motion and there is a large coaptation gap.

 

Conclusion

 

The study main findings were

  • Short, thickened, echogenic and immobile tricuspid leaflets with complete absence of coaptation and torrential tricuspid regurgitation.
  • Thickened pulmonary valve cusps with severe restriction of at least one cusp and severe pulmonary regurgitation.

These echocardiographic findings with severe thickening and rigidity of leaflets leading to free regurgitation in both tricuspid and pulmonary valves is the typical pattern of cardiac carcinoid disease.