Isolated Right Heart Failure in a Patient with Carcinoid Syndrome Reza Masoomi, MD, Jane Broxterman, MD, Rajat Barua, M.D., Deepak Parashara M.D. Introduction The isolated right ventricle failure is caused by a variety of causes including pulmonary vascular diseases, right ventricular cardiomyopathy, or valvular heart disease. Carcinoid heart disease(CHD) , which is a rare manifestation of carcinoid disease, characterized by plaque-like deposits of fibrous tissue on endocardium secondary to longstanding exposure to excess amount of biogenic amines like serotonin. We present a case of isolate right heart failure secondary to severe tricuspid valve regurgitation (TR) in setting of carcinoid hear syndrome. . Case Presentation On presentation, vital signs were within normal limits. A complete blood cell count, troponin and comprehensive metabolic panel were unremarkable. Pertinent physical examination included 10 cm JVP, decreased breath sounds in right base, 2/6 systolic murmur in left sternal border and 3+ bilateral lower extremities edema. The amplitude of QRS complexes in limb leads were < 5mm (fig.2). Echocardiography was perfumed and showed normal left ventricular systolic function and pulmonary artery pressure. However, it showed severe right ventricular and atrial enlargement, and tricuspid regurgitation. (fig.3)  A 66 year-old man with past medical history of primary carcinoid of unknown origin with hepatic involvement(fig.1) presented with weight gain, dyspnea and bilateral lower extremities edema of one month duration. He denied any chest pain, fever, chills, orthopnea, PND, palpitation or cough. Pt was diagnosed with metastatic carcinoid disease 6 years ago. He had underwent a TACE procedure and then he was also started on CarboPlatin and Etoposide in last year and then it was switched to Everolimus therapy and Octreotide monthly. Fig.3 Fig.1 Fig.2 Discussion Over 50 percent of patients with carcinoid syndrome will develop CHD and in up to 20 percent of cases, it can be the initial presentation. It usually affects the right heart valves and endocardium. The ECG in patients with CHD has a higher frequency of low-voltage QRS. As low voltage EKG was seen in our case, it can be a clue to the diagnosis of CHD in early stage. CHD should always be in differential diagnosis in patients with intrinsic tricuspid and pulmonary valve disease. The University of Kansas Medical Center