A 72-year-old gentleman presented with right heart failure (RHF) from tricuspid insufficiency. He also noted episodes of diarrhoea and flushing. Echocardiogram showed severe tricuspid regurgitation (TR) with thickened tricuspid leaflets (Panel A). The subcostal view revealed a hepatic mass, which, following biopsy and evaluation of 5-hydroxytryptamine, was confirmed as metastatic carcinoid tumour (Panel B). Carcinoid heart disease (CHD), namely TR, is the initial presentation of carcinoid tumours in up to 20% of patients. Serotonin, by activating the 5-HT(2B) receptor, induces fibrous tissue deposition on the endocardial surface of valvular cusps and cardiac chambers. Pulmonary vascular endothelial cells metabolise serotonin protecting the left heart chambers.