Transcatheter tricuspid valve replacement in carcinoid heart disease: A multimodality‑guided, patient-centered approach

Clinical Presentation

• A 74-year-old woman presented with chronic diarrhoea (5–8 episodes/day) and unintentional weight loss (11 kg over 12 months). She was diagnosed with carcinoid syndrome secondary to a well-differentiated small-bowel neuroendocrine tumour (NET). Medical therapy resulted in good control of systemic carcinoid symptoms.
• Over subsequent months, she developed progressive exertional dyspnoea (NYHA class III) with marked fatigue. There was no chest pain, orthopnoea, or paroxysmal nocturnal dyspnoea. She was a lifelong non-smoker with no history of hypertension, diabetes, dyslipidaemia, or known cardiovascular disease.

Examination

• BP 116/76 mmHg, HR 88 bpm, normal oxygen saturation
• BMI 20 kg/m²
• Elevated JVP and a soft systolic murmur at the lower left sternal edge
• No peripheral oedema

ECG

• Sinus rhythm
• Normal QRS duration and R-wave progression

Laboratory findings

• Haemoglobin: 123 g/L
• eGFR: 48 mL/min
• NT-proBNP: 8,154 ng/L
• ALP: 645 U/L
• Bilirubin: 24 µmol/L

Cardiac imaging and haemodynamics

Echocardiography

• Normal LV size and preserved systolic function
• Thickened mitral and aortic valves without haemodynamically significant left-sided disease

Torrential tricuspid regurgitation

• Vena contracta: 13 mm
• EROA: 1.8 cm²
• Regurgitant volume: 74 mL

Moderately dilated RV with preserved systolic function (FAC 47%)

Tricuspid valve morphology consistent with carcinoid involvement:

• Thickened, retracted, and plastered septal leaflet
• Anterior leaflet continuity with chordae and papillary muscle
• Markedly restricted leaflet motion

Invasive Haemodynamic

• Normal coronary arteries
• Mean PAP: 15 mmHg
• PCWP: 11 mmHg
• PVR: 1.6 WU
• Cardiac output: 2.5 L/min
• Cardiac index: 1.7 L/min/m²

Heart Team assessment

• TRI-SCORE: 6/12
• Predicted surgical mortality: 22%

Surgery deemed high risk due to:

• Advanced age
• Significant weight loss and sarcopenia
• Systemic disease burden from carcinoid syndrome

Consensus: Transcatheter intervention preferred.