Carcinoid: Bringing Closure to PFO

Background: There is an increased prevalence of patent foramen ovale (PFO) in patients with carcinoid heart disease (CHD).

Case: A 67-year-old woman presented with dyspnea on exertion for 1 month associated with epigastric pain, weight loss and diarrhea. She was tachypneic, with oxygen saturation of 90 % on 30 liters per minute. There was grade 2/6 systolic murmur at left sternal border and raised jugular venous pulse. Alpha-fetoprotein, cancer antigen 19-9 and carcinoembryonic antigen were normal. Urine 5-hydroxyindoleacetic acid, serum serotonin and chromogranin A were high. Computed Tomography (CT) scan of chest ruled out pulmonary embolus. CT scan of abdomen showed hepatic metastatic masses, proven to be carcinoid tumor on biopsy. Transthoracic echocardiogram showed right to left shunt via PFO with early thickening of the mitral valve. There was severe regurgitation of tricuspid and pulmonic valves.

Decision-making: Progression of right valvular CHD and reduced right atrial compliance from endocardial damage causes elevated right heart pressures, hence PFO resumption. Octreotide calmed her symptoms. Right heart catheterization and intra-cardiac echo guided percutaneous PFO closure with a 16 mm Cribriform ASD device was done. Hypoxia resolved.

Conclusion: Relief of hypoxia and mortality benefit from improved function are derived with PFO closure. Screening for PFO is vital because of a high risk of worsening right CHD and developing left CHD as serotonin bypasses lung deactivation.