Quadrivalvular Carcinoid Heart Disease Via Patent Foramen Ovale as Initial Presentation of Metastatic Neuroendocrine Tumor

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  Visual Summary. Quadrivalvular Carcinoid Heart Disease Mediated By Patent Foramen Ovale Clinical Course, Management, and Oncologic Outcomes in a 52-Year-Old Woman With Occult Metastatic Neuroendocrine Tumor BNP = B-type natriuretic peptide; CHD = carcinoid heart disease; CT = computed tomography; ECG = electrocardiogram; IV = intravenous; MRI = magnetic resonance imaging; NET = neuroendocrine tumor; PET = positron emission tomography; PFO = patent foramen ovale; 5-HIAA = 5-hydroxyindoleacetic acid.

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  Figure 1. Chest X-Ray With Small Right-Sided Pleural Effusion Computed tomography pulmonary embolism with large right-sided effusion not seen in chest x-ray and minimal left-sided effusion.

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  Figure 2. Transesophageal Echocardiography Showing Thickened and Malcoapted Tricuspid Valve With Severe Regurgitation Transesophageal echocardiography midesophageal view showing thickened, retracted, and severe malcoaptation of tricuspid valve (A) with resultant severe tricuspid regurgitation (B, C). Continuous-wave Doppler with dense triangular shape jet with rapid systolic decline characteristic of severe tricuspid regurgitation (D). RA = right atrium; RV = right ventricle; RVOT = right ventricular outflow tract.

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  Figure 3. Transesophageal Echocardiography Showing Restricted Mitral Valve With Severe Regurgitation Transesophageal echocardiography midesophageal view showing thickened, mitral valve restricted posterior leaflet and prolapse of the anterior leaflet (A) with resultant severe posteriorly directed mitral regurgitation (B, C). Continuous-wave Doppler with dense jet suggestive of severe MR (D). Abbreviations as in Figure 2.

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  Figure 4. Transesophageal Echocardiography Images Showing Severe Regurgitation of All 4 Valves and a Bidirectional Patent Foramen Ovale Ao = aorta; LVOT = left ventricular outflow tract; other abbreviations as in Figure 2.

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  Figure 5. Intra Operative Findings During Triple Valve Replacement Surgery Intraoperative findings (A) thickened, fibrotic, and noncoapted tricuspid valve. (B) Thickened and fibrotic mitral valve with anterior leaflet prolapse.

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  Figure 6. Findings on Gallium - 68 DOTATATE Positron Emission Tomography/Computed Tomography Gallium-68 DOTATATE positron emission tomography/computed tomography scan showing soft tissue mass in the left mid abdomen (red arrow) and ill-defined hypodensity in hepatic segment V (yellow arrow).

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  Figure 7. Findings on Computed Tomography of Abdomen Computed tomography of abdomen demonstrates a necrotic mass in the inferior right hepatic lobe measuring approximately 5.2 × 6.0 cm (yellow arrow) and a mesenteric mass in the left hemiabdomen measuring approximately 2.6 × 2.6 cm (red arrow) suspicious for metastatic neuroendocrine disease.

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  Figure 8. Findings on Magnetic Resonance Imaging of Abdomen Magnetic resonance imaging of the liver showing an enhancing mesenteric mass in the left hemi abdomen measuring approximately 2.7 × 2.4 cm (red arrow) and a heterogeneously enhancing mass (yellow arrow) arising from the hepatic segment 5 extending into the adjacent mesentery abutting the ventral abdominal wall measuring approximately 5.5 × 6.1 cm. The hepatic mass demonstrates focal areas of variable intrinsic T1 and T2 hyperintensity, suggesting cystic and hemorrhagic/proteinaceous contents.