CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 4, May 2012
e10
AFRICA
significant tricuspid regurgitation and stenosis, respectively (Fig.
2b, c).
After intravenous administration of gadolinium-based contrast
agent, delayed enhancement of the tricuspid valve and endocardial
layer of the right cardiac chambers was evidenced, indicating a
fibrous carcinoid plaque deposited on the endocardium (Fig. 2d).
The global systolic function of both ventricles was maintained.
A small circular pericardial effusion was present, without
pericardial thickening or pathological enhancement. No signs of
left-sided carcinoid heart disease were found.
Discussion
Carcinoid tumours are slow growing and indolent, but
development of CHD symptoms dramatically reduces life
expectancy. Standard palliative therapy in CS, therapy with
somatostatine analogues, although reducing levels of serotonin
and achieving good control of other CS symptoms in almost
80% of patients, does not induce regression of the cardiac
manifestations and most of the patients with carcinoid tumours
die from progressive right heart failure as a consequence of
regurgitation and stenosis of the tricuspid and pulmonary valves.
As surgical intervention with annuloplasty or valve
replacement is often the only therapeutic option, it is important
to follow up the patients regularly to detect the proper timing
for surgery. In recent reports, operative risk has declined to
below 10% when surgical intervention was performed before
the development of severe right heart failure, in even mildly
symptomatic patients where the referral to surgery was based on
severe valvular dysfunction and signs of right ventricular volume
overload.
Therefore, the most precise imaging technique should be
used for evaluation of right ventricular volumes and function.
While interobserver variability of quantitative assessment
of the right ventricular ejection fraction by two-dimensional
echocardiography is up to 15
±
13%,
1
MRI shows much lower
values, around 4%,
2
and should be in our opinion, the reference
standard for follow up of patients with CHD.
Since the first description of the MRI findings of CHD,
3
only
a few reports of the MRI features of this condition have been
published.
4-7
Most of these features are similar to those observed
echocardiographically, as shown in our patient – tricuspid and/
or pulmonary valve thickening and immobility with consequent
valvular dysfunction and right heart enlargement.
A single article reporting contrast-enhancement characteristics
of CHD was found where delayed enhancement of the tricuspid
septal leaflet, mostly marked at the annulus, was demonstrated.
4
In our patient, endocardial enhancement of the right atrium, right
ventricle including the endocardial surface of the subvalvular
apparatus, and both sides of the tricuspid valve was observed.
Conclusion
We believe that this type of late enhancement, not previously
described in the literature, perfectly corresponds with the well-
known histological features of CHD.
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