Introduction Cardiac abnormalities are seen in 15–70% of patients with carcinoid disease, typified by fibrosis of the right sided valves. Myocardial abnormalities in subjects without overt carcinoid heart disease have not been previously described. Tissue Doppler imaging has demonstrated early myocardial abnormalities in diabetic and hypertrophic cardiomyopathies (disease processes characterised by myocardial fibrosis). We investigated whether, myocardial fibrosis manifesting as early myocardial abnormalities, might be present in patients with carcinoid disease using tissue Doppler imaging.
Method We prospectively recruited 59 patients with metastatic mid-gut carcinoid disease and 10 normal controls. Six patients with 2D echocardiographic evidence of overt carcinoid heart disease were excluded. Subjects underwent transthoracic echocardiography using a GE Vivid 7 or Vivid Q machine (2.5 MHz phased array transducer). Colour tissue Doppler loops (3 cardiac cycles) in each of the apical 4-chamber, 2-chamber and long axis imaging planes were acquired triggered to the ECG and saved digitally for subsequent off line analysis by a single experienced operator data (Echopac V9.01, GE, Horten, Norway). Regional myocardial velocity curves were derived using a 6x6 mm sample volume placed in the basal segment of each of the septal, lateral, anterior, inferior, posterior and antero-septal left ventricular walls. For the right ventricle the basal segment in the 4-chamber view was used. Strain and strain rate curves were generated from the same data set using a 5×12 mm sample volume placed in the basal segment. All sample volumes were manually tracked to correct for cardiac displacement.
Results The age of control subjects and carcinoid disease patients was 54±13.2 and 62±11.4 years respectively, (p=ns). The proportion of males were 50% in control and 51% in the carcinoid disease groups respectively (p=ns). Characteristics of the carcinoid group included: 70% (n=37) with carcinoid syndrome, 58% (n=31) with liver metastases on cross sectional imaging and 58% (n=31) taking somatostatin analogues (treatment to reduce symptoms of carcinoid syndrome). Abstract 090 Table 1 shows the tissue Doppler results for the two groups. Left ventricular diastolic tissue velocities (E' and A') and peak early diastolic strain rate (PEDSR) were reduced in carcinoid patients compared to controls. There were no significant differences in the right ventricular data.
Conclusion We have demonstrated abnormal diastolic myocardial characteristics in the left but not the right ventricle in patients without overt carcinoid heart disease. Our results support a hypothesis of sub-clinical myocardial fibrosis in these patients. Further investigation into the natural history of these changes, progression to valvular heart disease and their modification by treatment is warranted.
- carcinoid heart disease
- tissue Doppler imaging
- myocardial fibrosis