A Royal Flush: Carcinoid Heart Disease Complicated by Severe Tricuspid and Pulmonic Valve Regurgitation

Carcinoid heart disease (CHD) is a severe complication of metastatic neuroendocrine tumors (NETs), leading to fibrotic degeneration of right-sided heart valves. A 38-year-old male presented with progressive dyspnea, fatigue, abdominal bloating, diarrhea, and facial flushing. Imaging revealed hepatic metastases and mesenteric lymphadenopathy, and biochemical markers confirmed a NET of likely gastrointestinal origin. Echocardiography showed torrential tricuspid regurgitation, severe pulmonary insufficiency, right ventricular dilation, and a patent foramen ovale (PFO). The patient was started on long-acting lanreotide for carcinoid syndrome and optimized on heart failure therapy. Due to severe valvular dysfunction, he underwent tricuspid and pulmonic valve replacement with bioprosthetic valves and PFO closure under perioperative octreotide infusion. The patient also underwent transthoracic liver debulking and ablation, small bowel resection, and mesenteric dissection. Postoperatively, he showed symptomatic improvement and remains under multidisciplinary surveillance. This case highlights the importance of early recognition, multidisciplinary management, and surgical intervention in CHD to optimize outcomes. Early initiation of somatostatin analog therapy, guideline-directed medical therapy for heart failure, and timely surgical intervention can significantly improve symptom burden and survival.