Reversible Right-Sided Heart Failure Secondary to Carcinoid Crisis

Carcinoid crisis is an infrequent and little-described complication of neuroendocrine tumors that can be life threatening. It may develop during induction of anesthesia, intraoperatively, during tumor manipulation and arterial embolization, or even spontaneously. The massive release of neuroendocrine substances can lead to potentially fatal complications. Somatostatin analogs inhibit the release of these substances and are the mainstay of treatment. The following case report describes a patient with reversible acute right-sided heart failure posterior to hepatic artery embolization. 1. Case Presentation A 41-year-old female patient without a significant medical history presented symptoms that evolved over a period of one year, initiating with jaundice and epigastric pain. A computerized axial tomography of the abdomen was performed, which showed an increased liver size with multiple hepatic lesions and dilation of the intrahepatic bile duct. Magnetic resonance cholangiography evidenced a solid 9？cm mass and lesions suggestive of hepatic neoplastic compromise. A hepatic biopsy was done, which documented low grade compromise caused by a neuroendocrine tumor (grade 1). The OctreoScan showed multiple enhancing lesions in the liver with multifocal tumoral compromises with somatostatin receptors. Positron emission tomography evidenced hypermetabolic hepatic lesions consistent with a malignant pathology. Initial workup showed chromogranin A, 99.5？μg/L, and 5-hydroxyindoleacetic acid, 10.3？mg. A diagnosis of low grade neuroendocrine tumor (well-differentiated tumor, histological grade WHO 2), with unknown primary and with documented hepatic metastases, was made. The case was presented to the neuroendocrine tumors committee and treatment with transarterial hepatic embolization was considered. A preprocedural transthoracic echocardiogram was conducted, which appeared normal. Initially, the patient was in a good general state. Blood pressure was 130/70？mmHg, and heart rate was 75 beats/minute, without other significant findings on physical examination. On the second day of hospitalization, hepatic arterial embolization was performed without chemotherapy using polyvinyl alcohol particles, without complications. On the fourth day of hospitalization, the patient presented deterioration in the functional class and on physical examination presented moderate jugular ingurgitation and edema of lower limbs. Computerized axial tomography was performed, which ruled out pulmonary thromboembolism; a transthoracic echocardiogram showed left ventricular systolic function in the