NPPB and tricuspid valve insufficiency: Echocardiography (TTE): TTE should be performed in all patients with carcinoid syndrome and a high suspicion for cardiac involvement consistent with clinical features such as cardiac murmurs, raised brain natriuretic peptide (BNP), or pro-b-type natriuretic peptide (proBNP) with or without thickening and retraction of immobile tricuspid valve leaflets and pulmonary valve cusps with associated tricuspid regurgitation [34].