tricuspid and pulmonic valve disease - dr. stultz 01 13 tricuspid and pulmonic... · tricuspid...
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Tricuspid andTricuspid and PulmonicPulmonic Valve DiseaseValve DiseaseThe Forgotten ValvesThe Forgotten Valves
David Stultz, MD, FACCDavid Stultz, MD, FACC
Southwest Cardiology, Inc.Southwest Cardiology, Inc.
January 13, 2009January 13, 2009
(c) 2000-2008 David Stultz, MD
Goals of ConferenceGoals of Conference
Understand Tricuspid andUnderstand Tricuspid and PulmonicPulmonic valvevalvestenosisstenosis and regurgitationand regurgitation
DiagnosisDiagnosis
Treatment optionsTreatment options
Specific conditionsSpecific conditions
EbsteinEbstein anomalyanomaly
Carcinoid SyndromeCarcinoid Syndrome
(c) 2000-2008 David Stultz, MD
A Few BasicsA Few Basics
Venous WaveformVenous Waveform
Understanding Echo terminology with respectUnderstanding Echo terminology with respectto pressure gradients andto pressure gradients and stenosisstenosis
(c) 2000-2008 David Stultz, MD
Right Atrial WaveformRight Atrial Waveform
a wave - RA contractionelevated in RV failure
c wave - tricuspid closurev wave - passive filling of RA duringventricular systole = T wave on ECG
elevated in tricuspid regurgitationx descent - atrial diastoley descent - atrial emptying
http://www.staff.vu.edu.au/CriticalCare/Critical%20Care/lecture2_notes.htm
(c) 2000-2008 David Stultz, MD
UnderstandingUnderstanding StenosisStenosis and Pressureand PressureGradientsGradients
No “Stenosis” at the end of the hoseNo SIGNIFICANT Pressure gradientNo impedence to water flow
Now there is a “Stenosis” at the end of the hoseSIGNIFICANT Pressure gradient across the thumbWater flow impeded, creating increased velocity
Put Thumb on hose
(c) 2000-2008 David Stultz, MD
Tricuspid Valve AnatomyTricuspid Valve Anatomy
SL – Septal leaflet, AL – Anterior leaflet, PL – Posterior leaflet
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Feigenbaum, 6th ed
Right Ventricle InflowRight Ventricle Inflow(c) 2000-2008 David Stultz, MD
ParasternalParasternal Short AxisShort Axis
Feigenbaum, 6th ed
(c) 2000-2008 David Stultz, MD
Apical 4 ChamberApical 4 Chamber
Feigenbaum, 6th ed
(c) 2000-2008 David Stultz, MD
SubcostalSubcostal
Feigenbaum, 6th ed
(c) 2000-2008 David Stultz, MD
TEE 4 chamberTEE 4 chamber
Feigenbaum, 6th ed
(c) 2000-2008 David Stultz, MD
TEE RV inflowTEE RV inflow
Feigenbaum, 6th ed
(c) 2000-2008 David Stultz, MD
TricuspidTricuspid StenosisStenosis
EtiologyEtiology
Almost always rheumaticAlmost always rheumatic
Other causes are rareOther causes are rare
Congenital tricuspidCongenital tricuspid atresiaatresia
Right atrial tumorsRight atrial tumors
Carcinoid syndromeCarcinoid syndrome
More often tricuspid regurgitationMore often tricuspid regurgitation
EndomyocardialEndomyocardial fibrosisfibrosis
VegetationsVegetations
Pacemaker leadPacemaker lead
ExtracardiacExtracardiac tumorstumors
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Rheumatic TricuspidRheumatic Tricuspid StenosisStenosis
At autopsy, seen in 15% of patients withAt autopsy, seen in 15% of patients withrheumatic heart diseaserheumatic heart disease
But clinically significant in only 5%But clinically significant in only 5%
Isolated TS is rareIsolated TS is rare
Almost always mitral valve involvementAlmost always mitral valve involvement
Also aortic valve involvement commonAlso aortic valve involvement common
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Pathologic FindingsPathologic FindingsRheumatic TricuspidRheumatic Tricuspid StenosisStenosis
Similar to mitralSimilar to mitral stenosisstenosis
Fusion and shortening ofFusion and shortening of chordaechordae tendineaetendineae
Fusion of leaflet edgesFusion of leaflet edges
Calcification is rareCalcification is rare
Right atrial dilatation, wall thickeningRight atrial dilatation, wall thickening
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
PathophysiologyPathophysiology
Mean pressure gradient across tricuspid valve ofMean pressure gradient across tricuspid valve of5mmHg is enough to cause symptoms5mmHg is enough to cause symptoms
Jugular venous distensionJugular venous distension
AscitesAscites
EdemaEdema
Mean pressure gradient of 2mmHg is sufficientMean pressure gradient of 2mmHg is sufficientfor diagnosisfor diagnosis
Augmented by inspiration, fluid statusAugmented by inspiration, fluid status
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
SymptomsSymptoms
FatigueFatigue
Abdominal discomfortAbdominal discomfort HepatomegalyHepatomegaly
AscitesAscites
AnasarcaAnasarca
Neck discomfortNeck discomfort
DyspneaDyspnea,, orthopneaorthopnea rare with isolated TSrare with isolated TS More often these symptoms due to mitral valveMore often these symptoms due to mitral valve
diseasedisease
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Physical ExaminationPhysical Examination
Diastolic rumble at left lowerDiastolic rumble at left lower sternalsternal borderborder Increased with inspirationIncreased with inspiration
Often confused with mitralOften confused with mitral stenosisstenosis
Tricuspid opening snapTricuspid opening snap
Neck vein distentionNeck vein distention Prominent a waveProminent a wave
Slow y descentSlow y descent
Hepatic pulsationHepatic pulsation
AscitesAscites
Aortic and Mitral murmursAortic and Mitral murmurs
http://www.rjmatthewsmd.com/Definitions/venous_pulse.htmBraunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Maneuvers to Change intensity of Murmur inManeuvers to Change intensity of Murmur inTricuspidTricuspid StenosisStenosis
Increase MurmurIncrease Murmur InspirationInspiration Mueller maneuverMueller maneuver Right lateral decubitus positionRight lateral decubitus position Leg raisesLeg raises SquattingSquatting Isotonic exercise (hand grip)Isotonic exercise (hand grip) Amyl nitrite inhalationAmyl nitrite inhalation
Decrease MurmurDecrease Murmur ExpirationExpiration Strain phase of ValsalvaStrain phase of Valsalva
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Diagnostic EvaluationDiagnostic Evaluation
EchocardiographyEchocardiography Diastolic doming of leafletsDiastolic doming of leaflets
Thickening of leaflets, restricted motionThickening of leaflets, restricted motion
Doppler echo shows prolonged antegrade slopeDoppler echo shows prolonged antegrade slope
EKGEKG Right atrial enlargementRight atrial enlargement
ChestChest XrayXray Right atrial enlargementRight atrial enlargement
CatheterizationCatheterization Largely replaced by EchoLargely replaced by Echo
HemodynamicsHemodynamics
Angiography of RA shows a small diastolic jetAngiography of RA shows a small diastolic jet
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
ManagementManagement
Sodium restrictionSodium restriction
DiureticsDiuretics
Surgical managementSurgical management
Mean pressure gradient of 5mmHgMean pressure gradient of 5mmHg
Valve orifice area ofValve orifice area of ≤≤2.0cm22.0cm2
Often coexistent Mitral diseaseOften coexistent Mitral disease
TS + MSTS + MS –– fix both at same timefix both at same time
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Surgical TechniquesSurgical Techniques
OpenOpen valvotomyvalvotomy (Create a functional bicuspid(Create a functional bicuspidvalve)valve) OpenOpen commisurescommisures between anteriorbetween anterior--septalseptal andand
septalseptal--posterior leafletsposterior leaflets Not between anterior and posterior leafletsNot between anterior and posterior leaflets
Leads to severe regurgitationLeads to severe regurgitation
BioprostheticBioprosthetic valve replacementvalve replacement Preferred over mechanical due to risk ofPreferred over mechanical due to risk of
thromboembolismthromboembolism
BalloonBalloon valvuloplastyvalvuloplasty??
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Tricuspid RegurgitationTricuspid RegurgitationEtiologyEtiology
Secondary (functional) TRSecondary (functional) TR
Most CommonMost Common
Structurally Normal ValveStructurally Normal Valve
Due to dilatation of right ventricleDue to dilatation of right ventricle
Commonly due to mitral valve diseaseCommonly due to mitral valve disease
RV systolic pressure more than 55mmHg will cause TRRV systolic pressure more than 55mmHg will cause TR
Other etiologiesOther etiologies
Pulmonary hypertensionPulmonary hypertension
EisenmengerEisenmenger’’ss syndrome/Congenitalsyndrome/Congenital
RV infarctionRV infarction
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Tricuspid RegurgitationTricuspid RegurgitationEtiologyEtiology
Primary Causes (abnormal valve)Primary Causes (abnormal valve)
Less CommonLess Common
LupusLupusConnective Tissue DiseaseConnective Tissue Disease
FenfluramineFenfluramine--phenterminephentermineRadiation InjuryRadiation Injury
MethysergideMethysergide valvular diseasevalvular diseaseRheumatoid ArthritisRheumatoid Arthritis
EndomyocardialEndomyocardial fibrosisfibrosisCarcinoidCarcinoid
RepeatedRepeated EndomyocardialEndomyocardial biopsybiopsyProlapseProlapse (Floppy Valve)(Floppy Valve)
Pacemaker leadsPacemaker leadsEbsteinEbstein anomalyanomaly
Cardiac Tumors (RACardiac Tumors (RA MyxomaMyxoma))InfectiveInfective endocarditisendocarditis
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Carcinoid SyndromeCarcinoid Syndrome
Tricuspid regurgitation or combinedTricuspid regurgitation or combinedstenosisstenosis/regurgitation/regurgitation
Deposits of fibrous tissue onDeposits of fibrous tissue on endocardialendocardial surfacesurfaceof valvular cuspsof valvular cusps
Usually ventricular surface of tricuspid valveUsually ventricular surface of tricuspid valve
Causes adhesion to right ventricular wall,Causes adhesion to right ventricular wall,creating regurgitationcreating regurgitation
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
SymptomsSymptoms
Generally well toleratedGenerally well tolerated
Pulmonary hypertension + TR = decreasedPulmonary hypertension + TR = decreasedcardiac outputcardiac output
FatigueFatigue
Abdominal discomfortAbdominal discomfort HepatomegalyHepatomegaly
AscitesAscites
AnasarcaAnasarca
Neck discomfortNeck discomfort
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Physical ExaminationPhysical Examination
Jugular venous distensionJugular venous distension ProminentProminent cc--vv wavewave
Sharp y descentSharp y descent
MurmurMurmur Associated pulmonary HTNAssociated pulmonary HTN
PansystolicPansystolic murmurmurmur
Left lowerLeft lower sternalsternal borderborder
Loud P2Loud P2
Without pulmonary HTNWithout pulmonary HTN Low intensityLow intensity
Murmur in 1Murmur in 1stst half of systolehalf of systole
http://www.rjmatthewsmd.com/Definitions/venous_pulse.htmBraunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Diagnostic EvaluationDiagnostic Evaluation
EchocardiographyEchocardiography Tricuspid regurgitation severityTricuspid regurgitation severity
Right ventricular functionRight ventricular function
Pulmonary artery pressurePulmonary artery pressure
EKGEKG -- nonspecificnonspecific Incomplete RBBBIncomplete RBBB
Atrial fibrillationAtrial fibrillation
ChestChest XrayXray CardiomegalyCardiomegaly, right atrial enlargement, right atrial enlargement
Catheterization/HemodynamicsCatheterization/Hemodynamics RV systolic pressure <40 mmHg favors Primary causeRV systolic pressure <40 mmHg favors Primary cause
RV systolic pressure >55 mmHg favors Secondary causeRV systolic pressure >55 mmHg favors Secondary cause
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Surgical ManagementSurgical Management
Well tolerated without pulmonary HTNWell tolerated without pulmonary HTN ValvectomyValvectomy tolerated well, with right heart dilatation developing monthstolerated well, with right heart dilatation developing months
to years after surgeryto years after surgery
Primary causePrimary cause Usually requireUsually require bioprosthesisbioprosthesis
Secondary causeSecondary cause UsuallyUsually annuloplastyannuloplasty ring (in conjunction with mitral valve surgery)ring (in conjunction with mitral valve surgery)
May not require TV surgery if mild TR and normalMay not require TV surgery if mild TR and normal TriscupidTriscupid annulus sizeannulus size
EndocarditisEndocarditis in IV drug usein IV drug use ControversialControversial
ValvectomyValvectomy followed later byfollowed later by bioprosthesisbioprosthesis??
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Pulmonary Valve (TTE Short Axis)Pulmonary Valve (TTE Short Axis)
Feigenbaum, 6th ed
(c) 2000-2008 David Stultz, MD
Pulmonary Valve (TTE Long Axis)Pulmonary Valve (TTE Long Axis)
Feigenbaum, 6th ed
(c) 2000-2008 David Stultz, MD
PulmonicPulmonic ValveValve StenosisStenosis
EtiologyEtiology
CongenitalCongenital pulmonicpulmonic valvevalve stenosisstenosis
VariableVariable atresiaatresia,, dysplasticdysplastic valvevalve
Associated with NoonanAssociated with Noonan SydromeSydrome
May beMay be supravalvularsupravalvular
RhuematicRhuematic disease (uncommon)disease (uncommon)
CarcinoidCarcinoid
Cardiac TumorsCardiac Tumors
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Physical ExamPhysical Exam
Decreased intensity of P2Decreased intensity of P2
Possible thrill in 2Possible thrill in 2ndnd leftleft intercostalintercostal spacespace
(c) 2000-2008 David Stultz, MD
Treatment ofTreatment of PulmonicPulmonic ValveValveStenosisStenosis
PercutaneousPercutaneous BalloonBalloon ValvotomyValvotomy
Usually when mean pressure gradient across valve isUsually when mean pressure gradient across valve is50mmHg50mmHg
May require additionalMay require additional valvotomiesvalvotomies in futurein future
(c) 2000-2008 David Stultz, MD
PulmonicPulmonic Valve RegurgitationValve Regurgitation
EtiologyEtiology Dilatation ofDilatation of pulmonicpulmonic valve ring (Most Common)valve ring (Most Common)
Pulmonary hypertension (Any cause)Pulmonary hypertension (Any cause)
Pulmonary arteryPulmonary artery dilitationdilitation Connective tissue diseaseConnective tissue disease
InfectiveInfective endocarditisendocarditis
Less Common CausesLess Common Causes Surgical treatment forSurgical treatment for tetralogytetralogy ofof FallotFallot
Other Congenital causesOther Congenital causes
Carcinoid syndromeCarcinoid syndrome
SyphillisSyphillis
Chest traumaChest trauma
Pulmonary artery catheterizationPulmonary artery catheterization
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Carcinoid ofCarcinoid of PulmonicPulmonic ValveValve
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
SymptomsSymptoms
Similar to tricuspid regurgitationSimilar to tricuspid regurgitation
Tolerated well as long as pulmonary arteryTolerated well as long as pulmonary arterypressure is normalpressure is normal
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Physical ExaminationPhysical Examination
Low pitch diastolic murmur at left 3Low pitch diastolic murmur at left 3rdrd or 4or 4thth intercostalintercostalspacespace
S3 or S4 at left lowerS3 or S4 at left lower sternalsternal border, augmented byborder, augmented byinspirationinspiration
GrahamGraham--SteellSteell MurmurMurmur Pulmonary pressure >55mmHgPulmonary pressure >55mmHg High pitched, blowing decrescendo murmurHigh pitched, blowing decrescendo murmur LeftLeft parasternalparasternal area, starts after prominent P2area, starts after prominent P2 Increases with inspirationIncreases with inspiration Confused with aortic regurgitation murmurConfused with aortic regurgitation murmur
However AR is more commonHowever AR is more common
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Diagnostic EvaluationDiagnostic Evaluation
EchocardiographyEchocardiography Severity of regurgitationSeverity of regurgitation PulmonicPulmonic valve annulus sizevalve annulus size Pulmonary arterial pressurePulmonary arterial pressure
EKGEKG Without pulmonary hypertensionWithout pulmonary hypertension
Incomplete RBBBIncomplete RBBB
With pulmonary hypertensionWith pulmonary hypertension RV hypertrophyRV hypertrophy
XRayXRay and Angiographyand Angiography –– nonspecificnonspecific Cardiac MRICardiac MRI –– Assess PA dilatation, PR severityAssess PA dilatation, PR severity
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
ManagementManagement
Usually not severe enough alone to requireUsually not severe enough alone to requirespecific treatmentspecific treatment
Treatment of pulmonary hypertension usuallyTreatment of pulmonary hypertension usuallysufficientsufficient
Mitral valve surgeryMitral valve surgery
EndocarditisEndocarditis may require valve replacementmay require valve replacement
BioprosthesisBioprosthesis or allograft preferred foror allograft preferred forreplacementreplacement
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Specific DiseasesSpecific Diseases
EbsteinEbstein’’ss AnomalyAnomaly
Carcinoid SyndromeCarcinoid Syndrome
(c) 2000-2008 David Stultz, MD
Crawford & DiMarco, 2nd ed
(c) 2000-2008 David Stultz, MD
EbsteinEbstein’’ss AnomalyAnomaly
11--2 in 10,000 approximate incidence in live births2 in 10,000 approximate incidence in live births
Apical displacement of tricuspid valve leafletsApical displacement of tricuspid valve leaflets
Anterior leaflet never displacedAnterior leaflet never displaced
Variable leaflet deformityVariable leaflet deformity
““AtrializationAtrialization”” of right ventricular tissueof right ventricular tissue
Small right ventricle, large right atriumSmall right ventricle, large right atrium
Associated lesionsAssociated lesions
50% have atrial50% have atrial septalseptal defect or patent foramendefect or patent foramen ovaleovale
25% have accessory bypass tract25% have accessory bypass tract
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
EbsteinEbstein’’ss Anomaly (TTE Apical 4 chamber)Anomaly (TTE Apical 4 chamber)
Feigenbaum, 6th ed
(c) 2000-2008 David Stultz, MD
EKGEKG
http://pediatriccardiology.uchicago.edu/MP/CHD/Ebstein/Ebstein.htm
(c) 2000-2008 David Stultz, MD
Invasive catheterization of RVInvasive catheterization of RV
(c) 2000-2008 David Stultz, MD
ChestChest XrayXray(Infant)(Infant)
ACCSAP 6
(c) 2000-2008 David Stultz, MD
Natural HistoryNatural History
Variable!Variable!
If extreme, inIf extreme, in uteroutero deathdeath
If mild, may live into 9If mild, may live into 9thth decadedecade
Severe valve deformitySevere valve deformity –– symptoms develop insymptoms develop ininfancyinfancy
Moderate valve deformityModerate valve deformity –– symptoms insymptoms inadolescenceadolescence
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Indications for interventionIndications for intervention
Significant cyanosisSignificant cyanosis
RightRight--sided heart failuresided heart failure
Declining functional capacity (Declining functional capacity (≥≥Class IIIClass IIINYHA)NYHA)
Relative indicationsRelative indications
Paradoxical emboliParadoxical emboli
RecurrentRecurrent supraventricularsupraventricular arrhythmiasarrhythmias
Asymptomatic substantialAsymptomatic substantial cardiomegalycardiomegaly
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Surgical TechniquesSurgical Techniques
Tricuspid Valve RepairTricuspid Valve Repair Anterior leaflet cannot be tethered downAnterior leaflet cannot be tethered down Repair results inRepair results in ““monocuspidmonocuspid”” valvevalve
Valve replacementValve replacement –– bioprostheticbioprosthetic ConcomitantConcomitant
Accessory path ablationAccessory path ablation MAZE procedure if atrial fibrillation presentMAZE procedure if atrial fibrillation present Closure of PFO/ASDClosure of PFO/ASD
Unusual proceduresUnusual procedures BidirectionalBidirectional cavopulonarycavopulonary shuntshunt FontanFontan
1010--20% will develop20% will develop supraventricularsupraventricular arrhythmias afterarrhythmias after EbsteinEbsteinrepairrepair
Braunwald, 8th ed
(c) 2000-2008 David Stultz, MD
Carcinoid SyndromeCarcinoid Syndrome
Caused by carcinoid producing tumorCaused by carcinoid producing tumor
Symptoms of diarrhea and flushing, usually occurringSymptoms of diarrhea and flushing, usually occurringtogethertogether
Asthma less commonAsthma less common
1010--40% incidence of cardiac involvement40% incidence of cardiac involvement
About 10% of carcinoid tumors cause the carcinoidAbout 10% of carcinoid tumors cause the carcinoidsyndromesyndrome MostlyMostly midgutmidgut tumors cause syndrometumors cause syndrome
Caused by overproduction of 5HTCaused by overproduction of 5HT (5(5--Hydroxytryptophan)Hydroxytryptophan)
Harrsion’s, 17th ed
(c) 2000-2008 David Stultz, MD
Carcinoid Tumor Location, Frequency of Metastases, andCarcinoid Tumor Location, Frequency of Metastases, andAssociation with the Carcinoid SyndromeAssociation with the Carcinoid Syndrome
—3.913.6Rectum
Hindgut
50—<0.1Testis
50321.0Ovary
—32.20.4Liver
5518.6Colon
<138.84.8Appendix
13—0.5Meckel's diverticulum
914.9Ileum
958.41.8Jejunum
Midgut
135.727.9Bronchus, lung, trachea
517.80.3Gallbladder
2071.90.7Pancreas
3.4—2.0Duodenum
9.5104.6Stomach
——<0.1Esophagus
Foregut
Incidence of CarcinoidSyndrome
Incidence ofMetastases
Location(% of Total)
Harrsion’s, 17th ed
(c) 2000-2008 David Stultz, MD
(c) 2000-2008 David Stultz, MD
Diagnosis of CarcinoidDiagnosis of Carcinoid
Urinary 5HIAA (Urinary 5HIAA (HydroxyindolaceticHydroxyindolacetic acid)acid)
Normal excretion is 2Normal excretion is 2--8mg/day8mg/day
78% sensitivity, 100% specificity78% sensitivity, 100% specificity
Platelet serotoninPlatelet serotonin –– more sensitivemore sensitive
Plasma serotoninPlasma serotonin
SerumSerum chromograninchromogranin AA
Harrsion’s, 17th ed
(c) 2000-2008 David Stultz, MD
Anatomic LocalizationAnatomic Localization
CT scan combined with nuclear imagingCT scan combined with nuclear imaging
Carcinoid tumors often express highCarcinoid tumors often express high--affinityaffinitysomatostatin receptorssomatostatin receptors
IndiumIndium--111111--pentetreotide is apentetreotide is a radiolabeledradiolabeledsomatostatin analoguesomatostatin analogue
False positive uptake can occur withFalse positive uptake can occur withgranulomasgranulomas, wounds, thyroid disease, wounds, thyroid disease
Harrsion’s, 17th ed
(c) 2000-2008 David Stultz, MD
CT LocalizationCT Localizationcombined withcombined with
SomatastatinSomatastatin ReceptorReceptorScintigraphyScintigraphy
Harrsion’s, 17th ed
(c) 2000-2008 David Stultz, MD
TreatmentTreatment
Carcinoid Syndrome:Carcinoid Syndrome:
OctreotideOctreotide
Somatostatin analogueSomatostatin analogue
100mcg SQ q8h; up to 3 mg/day100mcg SQ q8h; up to 3 mg/day
Controls symptoms of diarrhea and flushingControls symptoms of diarrhea and flushing
InterferonInterferon
Hepatic arteryHepatic artery embolizationembolization
Surgical resectionSurgical resection
Harrsion’s, 17th ed
(c) 2000-2008 David Stultz, MD
Carcinoid effects on the HeartCarcinoid effects on the Heart
Seen with Carcinoid SyndromeSeen with Carcinoid Syndrome
Tricuspid andTricuspid and PulmonicPulmonic ValveValve
StenosisStenosis and Regurgitationand Regurgitation
(c) 2000-2008 David Stultz, MD
SummarySummary
TricuspidTricuspid StenosisStenosis
RheumaticRheumatic
Tricuspid RegurgitationTricuspid Regurgitation
Secondary CausesSecondary Causes
PulmonicPulmonic ValveValve StenosisStenosis
CongenitalCongenital
PulmonicPulmonic Valve RegurgitationValve Regurgitation
Secondary CausesSecondary Causes
(c) 2000-2008 David Stultz, MD
ReferencesReferences
Crawford MH,Crawford MH, DiMarcoDiMarco JP,JP, PaulusPaulus WJ. Cardiology 2WJ. Cardiology 2ndnd ed. New York:ed. New York: MosbyMosby,,20042004
FauciFauci AS,AS, BraunwaldBraunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL,E, Kasper DL, Hauser SL, Longo DL, Jameson JL,LoscalzoLoscalzo J: Harrison's Principles of Internal Medicine, 17J: Harrison's Principles of Internal Medicine, 17thth ed. McGrawed. McGraw--HillHillProfessional, 2008.Professional, 2008.
FeigenbaumFeigenbaum H, Armstrong WF, Ryan T: Echocardiography 6H, Armstrong WF, Ryan T: Echocardiography 6thth ed.ed. LippincottLippincottWilliams & Wilkins, 2004.Williams & Wilkins, 2004.
Libby P,Libby P, BonowBonow RO, Mann DL,RO, Mann DL, ZipesZipes DP:DP: Braunwald'sBraunwald's Heart Disease: AHeart Disease: ATextbook of Cardiovascular Medicine 8Textbook of Cardiovascular Medicine 8thth ed. Philadelphia, WB Saunders,ed. Philadelphia, WB Saunders,20072007
(c) 2000-2008 David Stultz, MD