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CARDIOVASCULAR ANESTHESIOLOGY

Intraoperative Management of Patients with Carcinoid Heart Disease Having Valvular Surgery: A Review of One Hundred Consecutive Cases

Toby N. Weingarten, MD^*, Martin D. Abel, MD^*, Heidi M. Connolly, MD, Darrell R. Schroeder, MS, and Hartzell V. Schaff, MD

From the *Department of Anesthesiology, the Division of Cardiovascular Disease, the Division of Cardiac Surgery, and the Section of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota.

Address correspondence and reprint requests to Martin D. Abel, MD, Department of Anesthesiology, Mayo Clinic, 200 First St. SW, Rochester, MN 55905. Address e-mail to abel.martin{at}mayo.edu.

Abstract

BACKGROUND: Cardiac surgery for carcinoid heart disease is complicated by hemodynamic instability secondary to carcinoid crises, cardiovascular dysfunction, and blood loss. The safety of vasopressors and the benefit of aprotinin during concomitant octreotide administration are uncertain.

METHODS: We reviewed the effects of vasopressors and aprotinin on octreotide administration and mortality by univariate analysis in 100 consecutive cases of cardiac surgery for carcinoid heart disease from 1985 to 2003. Because mortality declines were temporally related to the introduction of aprotinin, bivariate analyses were performed to identify other factors associated with mortality.

RESULTS: Carcinoid symptoms and hypotension were treated with octreotide (n = 89) and/or vasopressors (n = 93). Vasopressors were not associated with increased octreotide administration. Patients requiring epinephrine had higher mortality but also had worse preoperative New York Heart Association class, higher urinary 5-hydroxyindoleacetic acid levels, and increased blood transfusion requirements. Aprotinin (n = 54) was associated with decreased blood transfusion requirements, increased octreotide administration, but not mortality. Overall mortality was 13%, declining from 28% between 1985 and 1994 to 6% between 1995 and 2003. Mortality was associated with greater blood transfusion requirements and longer duration of cardiopulmonary bypass.

CONCLUSIONS: Vasopressors may be used in conjunction with octreotide in carcinoid patients. The increased mortality associated with epinephrine likely reflects selection bias rather than a primary adverse effect. The improved survival over time in carcinoid patients is multifactorial and unrelated to aprotinin administration, suggesting further inhibition of the kallikrein–kinin system has little added benefit for this outcome in the presence of octreotide.

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