2021 Volume 85 Issue 1 Pages 78-
A 77-year-old woman presented with edema in her extremities after undergoing chemotherapy for a neuroendocrine tumor that had occurred 5 years earlier. Transthoracic echocardiography revealed obviously increased sclerosis on all 3 cusps of the tricuspid valve (TV), representing a “locked TV”, despite normal mitral and aortic valves presenting normal left ventricular function.
The septal cusp was fixed in the open position (Figure A,B). The anterior and posterior cusps had decreased mobility and were in a semi-open position (Supplementary Movie 1). We noted severe TV regurgitation (TR) caused by cusp disruption (Figure C). The maximum TR flow velocity was 3.3 m/s with a cutoff sign (Figure D). There were no degenerative findings for the pulmonary artery valve (PV). Subsequently, we confirmed the same findings using multi-planar reconstruction of 3D-transesophageal echocardiography (3D-TEE). The volume-rendering method was useful for visual understanding of the anatomical positions (Figure E; Supplementary Movie 2).
The tricuspid valve is locked in the open position through systole (A) to diastole (B); with severe tricuspid regurgitation (C) with a cut-off sign (D; arrows). 3D-transesophageal echocardiography images (E). A, anterior cusp; P, posterior cusp; S, septal cusp.
She was extremely debilitated and not indicated for surgical treatment of the TV. Chemotherapy with streptozocin was continued, but she died 6 months later.
Carcinoid syndrome has an incidence of approximately 3% in the USA and Japan.1 When liver metastasis occurs, TV and PV degeneration, known as carcinoid heart disease, caused by direct influx of high concentrations of bioactive substances to the pulmonary circulation is observed in approximately 45–77% of cases. In the present case, there was less left heart degeneration because the bioactive substances were inactivated in the lungs.
In conclusion, 3D-TEE was useful for understanding the etiology visually. These distinctive findings should be shared.
The authors declare that there are no conflicts of interest.
Supplementary Movie 1. The movie of two-dimensional transthoracic echocardiography focused in tricuspid valve.
Supplementary Movie 2. The movie of the volume-rendering method in 3D-TEE observed from the right atrium.
Please find supplementary file(s);
http://dx.doi.org/10.1253/circj.CJ-20-0779
