TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Common presentations of carcinoid syndrome include flushing, palpitations, secretory diarrhea, bronchospasm and hypotension. In 20% of patients, symptoms may present initially with progressive exertional dyspnea indicating possible carcinoid heart disease (CHD). CASE PRESENTATION: A 74 y/o AA F with history T2DM, HTN, dyslipidemia, COPD, asthma presented with progressive exertional dyspnea for 6 month and 1 month history of diarrhea. Her physical exam was pertinent for T 36.2°C, BP 136/86, HR/80, RR/18 saturating 95%, loud blowing holosystolic murmur, bilateral LE pitting edema and abdominal ascites. Laboratory were significant for Na 147 mmol/L, K 2.9 mmol/L, creatinine at 1.65 mg/dL, BUN at 23 mg/dL and elevated NT-proBNP 4,866 pg/mL. A TTE showed normal LV systolic function with EF of 50-55% and severe RV and atrial dilatation, severe TR and dyssynergia with a flattened septum and PA of 50-55 mmHg. She underwent RHC which showed elevated right-sided filling pressures and low CO/CI. She was admitted to the hospital and was treated with aggressive diuresis and started on dobutamine. Further work up looking for infiltrative diseases were performed including ANA w/ reflex, RF, SPEP/UPEP, and Kappa/Lambda ratio and were all normal. CT scan showed an incidental hypodense lesion in the right hepatic dome. Serum serotonin was elevated at 930 ng/mL, 24 hr for 5-HIAA at 177mg/d and chromogranin A 3,257 ng/mL. She was started on octreotide and FNA of the right liver lesion was positive for a low-grade/well-differentiated neuroendocrine tumor. The patient was maintained on octreotide therapy for symptomatic relief and no further management was pursued due to critical health condition. DISCUSSION: CHD has an insidious presentation. Patients may be asymptomatic until the tumor metastasizes to the liver. A high suspicion coupled with serologic and imaging tests is crucial for earlier diagnosis. The left side of the heart is usually spared because the lungs metabolize the vasoactive substances before reaching the left-sided heart valves. Rarely, when the disease is found on the left side of the heart usually a right-to-left shunt is present. Typical TTE findings show a pattern of RV volume overload with enlarged RV and TV leaflet thickening. CONCLUSIONS: Early detection of carcinoid heart disease can improve prognosis and symptoms in patients with heart valve involvement. Treatment is aimed for symptomatic relief with somatostatin-analogs, telotristat therapy and temporary diuretic therapy with definitive surgical valve replacement. REFERENCE #1: Ram P et al, Carcinoid Heart Disease: Review of Current Knowledge. Tex Heart Inst J. 2019 Feb; 46(1): 21–27. REFERENCE #2: Fox DJ and Khattar RS. Carcinoid heart disease: presentation, diagnosis, and management. Heart. 2004 Oct; 90(10): 1224–1228. REFERENCE #3: Agha AM, Lopez-Mattei J, Donisan T, et alMultimodality imaging in carcinoid heart diseaseOpen Heart 2019;6:e001060. doi: 10.1136/openhrt-2019-001060 DISCLOSURES: No relevant relationships by Katherine Orengo Gomez, source=Web Response