RESUMO
AIMS: Echocardiographic assessment of cancer-associated non-bacterial thrombotic endocarditis (Ca-NBTE) is limited to case reports and small clinical series. The study aimed to identify heart valve abnormalities and its relation to embolic complications and cancer types. METHODS AND RESULTS: Manual review of echocardiographic images and medical records of Mayo Clinic patients (31 March 2002-30 June 2022) was performed. Ca-NBTE in 111 patients (mean age 63.2 ± 9.7 years, 66.7% female) predominantly affected mitral valves (MV) (69), 56 aortic (AV), 8 tricuspid (TV), and rarely pulmonic (PV) (1). In 18 patients, 2 valves were involved, 3 and 4 valve involvement in only a single patient each. Embolic complications were prevalent (n = 102, 91.9%). Ca-NBTE affected MV more frequently on the upstream (atrial) (90% vs. 49.3%) and TV downstream (ventricular) side (75% vs. 37.5%). NBTE size (cm) varied significantly among valves, with TV hosting the largest masses (0.63-2.40 × 0.39-1.77), compared with MV [(0.11-1.81 × 0.11-1.62), (length P = 0.001; width P = 0.03)] and AV [(0.20-2.70 × 0.11-1.51), (length P = 0.001; width P = 0.056)]; MV masses were borderline longer in systemic compared with cerebral emboli (P = 0.057). Majority of MV (79.6%) and AV (69.6%) had thickened leaflets. NBTE lesions commonly affected closing margins (73.9% MV, 85.7% AV, and 62.5% of TV) but rarely commissures of MV (8.7%), yet fairly frequently of AV (41.1%). Five patients had severe regurgitation of MV and 5 AV. CONCLUSION: Ca-NBTE manifests mainly as thrombotic mobile masses attached to thickened MV and AV, with distinct variations in size based on valve type. Embolic destination but not cancer type is associated with NBTE mass size and location.
Assuntos
Endocardite não Infecciosa , Neoplasias , Humanos , Feminino , Masculino , Pessoa de Meia-Idade , Endocardite não Infecciosa/diagnóstico por imagem , Endocardite não Infecciosa/complicações , Neoplasias/complicações , Neoplasias/diagnóstico por imagem , Estudos Retrospectivos , Ecocardiografia/métodos , Idoso , Trombose/diagnóstico por imagemRESUMO
Premortem clinical presentation of cancer-associated non-bacterial thrombotic endocarditis (Ca-NBTE), therapy, and the clinal course is limited to case reports and small clinical series. An electronic search of Mayo Clinic records (03/31/2002-06/30/2022) with a subsequent manual review was performed to identify adult patients with echocardiographically detected NBTE and active malignancy, excluding those with infectious endocarditis or lupus anticoagulant/antiphospholipid antibodies. In this retrospective cohort study, we analyzed 115 Ca-NBTE patients (mean age 63.2 ± 9.7 years, 66.1% female) involving 71 (61.7%) mitral, 58 (50.4%) aortic, 8 (6.9%) tricuspid, and 1 (0.9%) pulmonary valve. The most common cancer was lung (n = 45 cases (39.1%), followed by pancreatic (n = 19, 16.5%), gynecological (17, 14.8%), gastrointestinal (n = 10, 8.7%), and 10 (8.7%) with hematologic malignancy; 6 patients had two active cancers. Embolic complications at presentation were frequent: 94 (81.7%) brain, 11 splenic, 10 renal, 6 coronary, and 4 to the extremities. Of 104 anticoagulated patients, 60 received low molecular weight heparin, 17 unfractionated heparin, 16 apixaban, 8 warfarin, and 3 rivaroxaban. There were 18 arterial thromboembolisms; the Kaplan-Meier estimates of the incidence at 2 years were consistent with a rate of 15.9% [95% Confidence Interval (CI) 9.9-23.3], including 14 strokes (12.4%, 95%CI, 7.1-19.2), and 8 other arterial emboli (10.5%, 95%CI, 4.7-18.9); there were 10 venous thromboembolisms (8.9%, 95%CI, 4.5-15.0). Fourteen major bleedings occurred (12.8%, 95%CI, 7.3-19.9) and 94 patients died during follow-up (77.9%, 95%CI, 71.1-85.8). Ca-NBTE predominantly affected women with lung adenocarcinoma or digestive tract cancers and manifested by stroke with high mortality and frequent embolic and bleeding complications during anticoagulation therapy.
Assuntos
Endocardite não Infecciosa , Neoplasias , Humanos , Feminino , Pessoa de Meia-Idade , Masculino , Estudos Retrospectivos , Idoso , Endocardite não Infecciosa/complicações , Neoplasias/complicações , Anticoagulantes/uso terapêutico , Pirazóis/uso terapêutico , Neoplasias Pancreáticas/complicações , Piridonas/uso terapêuticoRESUMO
Nonbacterial thrombotic endocarditis (NBTE) is a manifestation of prothrombotic status observed in patients with malignancy. Most cases are discovered only in the advanced stages. However, cancer in early stages may also induce NBTE development. We herein report an 87-year-old man with NBTE with multiple thromboembolization coexisting with lung cancer in early clinical stage. Autopsy findings revealed platelet- and fibrin-rich vegetations in both the tricuspid and mitral valves without evidence of bacterial infection. NBTE should be considered in cases with occult thromboembolization. Not only the presence of typical vegetation but irregular leaflet thickening should be monitored with careful echocardiographic examinations.
Assuntos
Endocardite não Infecciosa , Endocardite , Neoplasias Pulmonares , Masculino , Humanos , Idoso de 80 Anos ou mais , Neoplasias Pulmonares/complicações , Endocardite/complicações , Endocardite/diagnóstico , Endocardite não Infecciosa/complicações , Endocardite não Infecciosa/diagnóstico por imagem , Valva Mitral/patologia , AutopsiaRESUMO
Nonbacterial thrombotic endocarditis (NBTE) is a distinctive condition marked by the presence of aseptic fibrin depositions on cardiac valves due to hypercoagulability and endocardial damage. There is a scarcity of large cohort studies clarifying factors associated with morbidity and mortality of this condition. A systematic literature review was performed utilizing the PubMed, Embase, Cochrane, and Web-of-Science databases to retrieve case reports and series documenting cases of NBTE from inception until September-2022. A descriptive analysis of basic characteristics was carried out, followed by multivariate regression analysis to identify risk factors associated with morbidity and mortality. A total of 416 case reports and series were identified, of which 450 patients were extracted. The female-to-male ratio was around 2:1 with an overall sample median age of 48 (interquartile range [IQR]:34-61). Stroke-like symptoms were the most common presentation and embolic phenomena occurred in 70% of cases, the majority of which were due to stroke. Cancer was associated with higher embolic complications (aOR:6.38, 95% CIâ¯=â¯3.75-10.83, p < 0.01) in comparison to other NBTE etiologies, while age, sex, and vegetation size were not (p > 0.05). All-cause in-hospital mortality was 36%, with cancer etiology being associated with higher mortality: 56% (aOR:3.64, 95% CIâ¯=â¯1.57-8.43, p < 0.01) in comparison to other NBTE etiologies:19%. A significant decrease in NBTE mortality was seen in recent years in comparison to admissions that occurred during the 20th century (aOR:0.07, 95% CIâ¯=â¯0.04-0.15, p < 0.01). While there has been an observed improvement in overall in-hospital mortality rates for patients admitted with NBTE in recent years, it is important to note that cases associated with a cancer etiology are still linked to high morbidity and mortality during hospitalization.
Assuntos
Endocardite não Infecciosa , Endocardite , Neoplasias , Acidente Vascular Cerebral , Humanos , Masculino , Feminino , Endocardite não Infecciosa/complicações , Endocardite/diagnóstico , Endocardite/epidemiologia , Endocardite/etiologia , Neoplasias/complicações , Acidente Vascular Cerebral/etiologia , Fatores de RiscoRESUMO
Marantic endocarditis is a rare condition associated with autoimmune disease, malignancy, and hypercoagulable states. It is characterized by sterile friable vegetations composed of fibrin and platelets that confer a high risk of systemic embolism. Here we showcase imaging that led to the diagnosis of an interesting case of marantic endocarditis secondary to metastatic malignancy.
Assuntos
Adenocarcinoma de Pulmão , Endocardite não Infecciosa , Endocardite , Neoplasias Pulmonares , Humanos , Adenocarcinoma de Pulmão/complicações , Endocardite/diagnóstico , Endocardite/diagnóstico por imagem , Endocardite não Infecciosa/etiologia , Endocardite não Infecciosa/complicações , Neoplasias Pulmonares/complicações , Neoplasias Pulmonares/diagnóstico por imagemRESUMO
BACKGROUND: Nonbacterial thrombotic endocarditis is a rare complication of prothrombotic states such as neoplasms that can cause valvular dysfunction and life-threatening complications. Nonbacterial thrombotic endocarditis usually affects the left-sided valves; however, only a minority of cases involving the tricuspid valve have been reported in medical literature. CASE PRESENTATION: The current report describes trivalvular involvement by nonbacterial thrombotic endocarditis in a 54-year-old Azeri female patient with metastatic colorectal carcinoma. This case underlines the necessity of evaluating nonbacterial thrombotic endocarditis as a possible consequence in cancer patients. When thromboembolic events are found in the presence of a hypercoagulable state (such as malignancy) and no growth on blood cultures, nonbacterial thrombotic endocarditis could be suspected as the cause. CONCLUSION: It is critical to achieve early diagnosis in such a setting to initiate treatment plans and prevent further complications rapidly.
Assuntos
Adenocarcinoma , Neoplasias do Colo , Endocardite não Infecciosa , Endocardite , Humanos , Feminino , Pessoa de Meia-Idade , Adenocarcinoma/complicações , Adenocarcinoma/patologia , Neoplasias do Colo/complicações , Endocardite não Infecciosa/etiologia , Endocardite não Infecciosa/complicações , Valva Tricúspide/diagnóstico por imagem , Endocardite/complicaçõesRESUMO
AIMS: We aimed to assess the role of multimodality imaging (MMI) in the diagnosis of marantic endocarditis (ME) associated with cancers and to describe the clinical characteristics, management, and outcome of these patients. METHODS AND RESULTS: In a retrospective multicentric study including four tertiary centres for the treatment of endocarditis in France and Belgium, patients with a diagnosis of ME were included. Demographic, MMI [echocardiography, computed tomography (CT), and 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT)], and management data were collected. Long-term mortality was analysed. Between November 2011 and August 2021, 47 patients with a diagnosis of ME were included. Mean age was 65 ± 11 years. ME occurred in 43 cases (91%) on native valves. Vegetations were detected by echocardiography in all cases and in 12 cases (26%) by CT. No patient had an increased cardiac 18F-FDG valve uptake. The most common cardiac valve involved was aortic (34 cases, 73%). Twenty-two patients (46%) had a known cancer before ME, and 25 cases (54%) were diagnosed thanks to multimodality imaging. 18FDG PET/CT was performed in 30 patients (64%) and allowed a new diagnosis of cancer in 14 patients (30%). Systemic embolism was frequent (40 patients, 85% of cases). Forty-one patients (87%) were treated medically with anticoagulation therapy. One-year mortality was 55% (26 patients). CONCLUSION: ME remains associated with a high risk of complications and death.
Assuntos
Endocardite não Infecciosa , Endocardite , Próteses Valvulares Cardíacas , Neoplasias , Humanos , Pessoa de Meia-Idade , Idoso , Tomografia por Emissão de Pósitrons combinada à Tomografia Computadorizada/métodos , Fluordesoxiglucose F18 , Endocardite não Infecciosa/complicações , Estudos Retrospectivos , Próteses Valvulares Cardíacas/efeitos adversos , Endocardite/complicações , Endocardite/diagnóstico por imagem , Imagem Multimodal , Estudos de Coortes , Neoplasias/complicações , Neoplasias/diagnóstico por imagem , Compostos RadiofarmacêuticosRESUMO
RATIONALE: Few isolated case reports and case series have reported arterial and venous thromboembolism related to adenomyosis; however, the underlying mechanism remains unclear. PATIENT CONCERNS: A 47-year-old woman presented with dizziness, nausea, vomiting, and loss of consciousness after red blood cell transfusion. She was being treated for menorrhagia and severe anemia. DIAGNOSES: Magnetic resonance imaging showed multiple infarctions in right cerebellum and bilateral frontal, parietal, and occipital lobes. Echocardiography performed during the evaluation for the source of emboli revealed multiple echogenic masses on the tricuspid aortic valve. There was no evidence of infection, and the masses on the aortic valve were diagnosed as nonbacterial thrombotic endocarditis. The levels of autoimmune antibodies and tumor markers except for carbohydrate antigen 19-9 and cancer antigen 125 were within the normal range. Uterine ultrasound showed a large adenomyosis. The patient was diagnosed with multiple cerebral and cerebellar infarctions due to nonbacterial thrombotic endocarditis, and hormone therapy and anticoagulation with warfarin were initiated. INTERVENTIONS: The patient did not develop recurrent infarction during anticoagulant therapy; however, menorrhagia worsened requiring total hysterectomy. OUTCOMES: The patient did not experience recurrent infarction despite the absence of anticoagulant therapy during the 3-year follow-up period. LESSONS: The present case adds to the limited number of previously reported cases and supports that, albeit rare, adenomyosis can be associated with embolic infarction and suggests that nonbacterial thrombotic endocarditis might be the link between adenomyosis and embolic infarction.
Assuntos
Adenomiose , Endocardite não Infecciosa , Endocardite , Menorragia , Pessoa de Meia-Idade , Feminino , Humanos , Adenomiose/complicações , Infarto Cerebral/etiologia , Infarto Cerebral/complicações , Endocardite não Infecciosa/complicações , Endocardite não Infecciosa/diagnóstico por imagem , Anticoagulantes , Infarto/complicações , Endocardite/complicaçõesRESUMO
BACKGROUND: Non-Bacterial Thrombotic Endocarditis (NBTE) is a common form of aseptic thrombotic endocarditis that primarily affects mitral valves and less frequently aortic valves. NBTE is caused by systemic inflammatory reactions. This condition induces valve thickening or attached sterile mobile vegetation. NBTE is mostly asymptomatic; however, major clinical manifestations result from systemic emboli rather than valve dysfunction. When significant damage occurs, valvular insufficiency or stenosis can appear and promote heart failure occasionally requiring valve replacement surgery. NBTE is associated with hypercoagulable states, systemic lupus erythematous (SLE), antiphospholipid syndrome, or malignancies. CASE PRESENTATION: We report successful biological aortic valve replacement surgery including cardiopulmonary bypass for a 78-year-old man with NBTE and voluminous vegetation on the aortic valve inducing moderate aortic insufficiency and acute heart failure. The histopathological analysis of the valve sample showed myxoid degeneration, fibrous remodeling, and partial necrosis without any bacteria, thus indicating marantic endocarditis. Initially, the patient presented to the emergency department with an acute stroke. He was already using Apixaban treatment for a history of atrial fibrillation and cardioembolic stroke. Because of the recurrence of stroke and appearance of aortic vegetation, the investigations were extended. The antiphospholipid antibodies were positive without any indication of bacterial endocarditis. The malignancy screening was positive for basal cell carcinoma (BCC). The surgery and postoperative course were uneventful, and the patient was discharged with vitamin K antagonists (VKA). To our knowledge, NBTE with such a volume is rare and its apparent association with BCC has not been previously reported. CONCLUSION: Outside of SLE and antiphospholipid syndrome, NBTE is a rare and underdiagnosed disease associated with thromboembolic events. Adequate anticoagulation is a cornerstone of its treatment. Anticoagulation management during perioperative care and valve surgery deserves specific attention and helps to protect the patient from embolic complications. In the case of stroke and thromboembolic events of unclear cause or suspected NBTE, echocardiography and thrombophilia assessments including an immunological workup are recommended.
Assuntos
Síndrome Antifosfolipídica , Carcinoma Basocelular , AVC Embólico , Embolia , Endocardite não Infecciosa , Endocardite , Lúpus Eritematoso Sistêmico , Acidente Vascular Cerebral , Tromboembolia , Masculino , Humanos , Idoso , Endocardite não Infecciosa/complicações , Endocardite não Infecciosa/diagnóstico , Síndrome Antifosfolipídica/complicações , AVC Embólico/complicações , Acidente Vascular Cerebral/etiologia , Embolia/complicações , Endocardite/complicações , Endocardite/diagnóstico , Tromboembolia/complicações , Lúpus Eritematoso Sistêmico/complicações , Carcinoma Basocelular/complicações , AnticoagulantesRESUMO
This paper reviews the current evidence on the pathogenesis, clinical manifestations, diagnosis and management of cancer-associated non-bacterial thrombotic endocarditis (NBTE). NBTE is an underdiagnosed condition characterized by sterile valvular vegetations composed of platelets and fibrin which are susceptible to systemic embolization. Cancer is a leading cause of NBTE and should be excluded in NBTE cases without a clear etiology. Malignancies most frequently associated with NBTE are mucin-releasing adenocarcinomas of the lung, ovary, biliary system, pancreas, breast and stomach. NBTE carries a high risk of arterial thromboembolism, while cardiac valvular dysfunction is much less frequent. NBTE appears to be an important underdiagnosed cause of cancer-associated embolic stroke of undetermined source. Characteristics associated with cancer-associated NBTE include elevated D-dimer, visceral infarcts, cerebral infarcts in multiple vascular territories, transcranial doppler microembolic signals, disseminated cancer and adenocarcinoma histology. Transesophageal echocardiography is the diagnostic test of choice, and all suspected cases should be evaluated for the presence of elevated D-dimers and disseminated intravascular coagulation. Long-term anticoagulation with low molecular weight heparin should be strongly considered, and surgical intervention is usually not needed. Underlying cancer must be diagnosed swiftly (if previously undiagnosed) and anti-cancer treatment should be initiated as soon as possible. The paucity of data regarding all aspects of NBTE, and the severe clinical consequences of untreated NBTE, are an urgent call for future research.
Assuntos
Adenocarcinoma , Endocardite não Infecciosa , Endocardite , Cardiopatias , Adenocarcinoma/complicações , Anticoagulantes , Endocardite/complicações , Endocardite/diagnóstico , Endocardite não Infecciosa/complicações , Feminino , Fibrina , Cardiopatias/complicações , Heparina de Baixo Peso Molecular , Humanos , MucinasAssuntos
Estenose da Valva Aórtica , Doença da Válvula Aórtica Bicúspide , Endocardite não Infecciosa , Endocardite , Neoplasias , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/microbiologia , Estenose da Valva Aórtica/complicações , Estenose da Valva Aórtica/diagnóstico por imagem , Endocardite/complicações , Endocardite/diagnóstico por imagem , Endocardite não Infecciosa/complicações , Endocardite não Infecciosa/diagnóstico por imagem , HumanosAssuntos
Insuficiência da Valva Aórtica , Endocardite Bacteriana , Endocardite não Infecciosa , Endocardite , Neoplasias , Valva Aórtica , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/tratamento farmacológico , Insuficiência da Valva Aórtica/etiologia , Endocardite/complicações , Endocardite/diagnóstico por imagem , Endocardite/tratamento farmacológico , Endocardite não Infecciosa/complicações , Endocardite não Infecciosa/diagnóstico por imagem , Endocardite não Infecciosa/tratamento farmacológico , Heparina/uso terapêutico , HumanosAssuntos
Humanos , Masculino , Adulto , Adulto Jovem , Endocardite não Infecciosa/complicações , Valvas Cardíacas/anormalidades , Lúpus Eritematoso Sistêmico/diagnóstico , Metilprednisolona/uso terapêutico , Ecocardiografia/métodos , Imunoglobulinas Intravenosas/uso terapêutico , Pulsoterapia/métodos , Ciclofosfamida/uso terapêuticoAssuntos
Anticorpos Antifosfolipídeos/sangue , Síndrome Antifosfolipídica/diagnóstico , Endocardite não Infecciosa/diagnóstico , Doenças das Valvas Cardíacas/diagnóstico , Artéria Retiniana , Doenças Retinianas/diagnóstico , Adulto , Anticorpos Antinucleares/análise , Síndrome Antifosfolipídica/sangue , Valva Aórtica/diagnóstico por imagem , Endocardite não Infecciosa/complicações , Feminino , Angiofluoresceinografia , Humanos , Artéria Retiniana/diagnóstico por imagem , Oclusão da Artéria Retiniana/diagnóstico por imagem , Doenças Retinianas/etiologia , Hemorragia Retiniana/diagnóstico por imagem , Hemorragia Retiniana/etiologia , Trombose/diagnósticoRESUMO
Described herein is a 48-year-old woman with metastatic ovarian cancer who developed aortic regurgitation considered clinically to be the result of infective endocarditis but operative resection of the three aortic valve cusps disclosed the valve lesions to be typical of non-bacterial thrombotic endocarditis (NBTE). Aortic regurgitation as a consequence of NBTE is rare but at least 9 cases have been reported previously.
Assuntos
Insuficiência da Valva Aórtica/diagnóstico por imagem , Endocardite não Infecciosa/diagnóstico por imagem , Neoplasias Ovarianas/complicações , Insuficiência da Valva Aórtica/etiologia , Insuficiência da Valva Aórtica/cirurgia , Diagnóstico Diferencial , Endocardite/diagnóstico , Endocardite não Infecciosa/complicações , Endocardite não Infecciosa/patologia , Endocardite não Infecciosa/cirurgia , Feminino , Implante de Prótese de Valva Cardíaca , Humanos , Pessoa de Meia-Idade , Metástase Neoplásica , Neoplasias Ovarianas/patologiaAssuntos
Insuficiência da Valva Aórtica , Endocardite não Infecciosa , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Insuficiência da Valva Aórtica/diagnóstico por imagem , Insuficiência da Valva Aórtica/etiologia , Ecocardiografia , Endocardite não Infecciosa/complicações , Endocardite não Infecciosa/diagnóstico por imagem , HumanosRESUMO
Nonbacterial thrombotic endocarditis, formerly known as marantic endocarditis, is a very rare complication of advanced malignancy and other hypercoagulable states in which sterile, fibrin vegetations develop on heart valve leaflets. The most common malignancies associated with this entity are lung, pancreatic and gastric cancer. It has also been described as a presentation of COVID-19, which is known to be frequently complicated with coagulopathy and thromboembolic events. We report the case of a 62 year-old female patient newly diagnosed with stage IV gastric cancer and acute SARS-CoV-2 infection, presenting with confusion and homonymous hemianopsia in the setting of multiple acute ischemic strokes complicating a nonbacterial thrombotic mitral endocarditis. Herein, we discuss the underlying pathophysiology and make the hypothesis that SARS-CoV-2 infection could have participated in the pathogenesis of nonbacterial thrombotic endocarditis in our patient suffering from a gastric cancer.
Assuntos
COVID-19 , Endocardite não Infecciosa , Neoplasias Gástricas , Endocardite não Infecciosa/complicações , Feminino , Humanos , Pessoa de Meia-Idade , SARS-CoV-2 , Neoplasias Gástricas/complicaçõesRESUMO
BACKGROUND: Antiphospholipid syndrome is an antibody mediated pro-thrombotic state leading to various arterial and venous thromboses. The syndrome can be either primary or secondary to other autoimmune diseases, commonly systemic lupus erythematosus. Cardiac involvement, in particular valvular disease is common in patients with antiphospholipid syndrome, occurring in about a third of these patients. Valvular diseases associated with antiphospholipid syndrome often occur as valve thickening and non-bacterial vegetation or Libman-Sacks endocarditis. Deposits of antiphospholipid immunoglobulin and complement components are commonly observed in the affected valves, suggesting an inflammatory process resulting in valvular vegetation and thickening. Libman-Sacks endocarditis has a high propensity towards mitral valve, although haemodynamically significant valvular dysfunction is rare. CASE PRESENTATION: We present a successful aortic valve replacement with cardiopulmonary bypass in a 48 years old lady with antiphospholipid syndrome, who has severe aortic regurgitation as a result of Libman-sacks endocarditis. Antiphospholipid antibodies were positive and the clinical data showed both negative cultures and infective parameters. Surgically resected vegetations revealed sterile fibrinous and verrucous vegetations on aortic valve. Valve replacement and the course of cardiopulmonary bypass was uneventful, and the patient was discharged well. CONCLUSIONS: Classically Libman-Sacks endocarditis is often and more commonly associated with autoimmune diseases such as systemic lupus erythematosus, although it can occur in both primary and secondary antiphospholipid syndrome. It is not a common entity, and it is a frequent underestimated disease as most clinicians do not routinely screen for valvular lesion in patients with antiphospholipid syndrome unless they are symptomatic. However, due to its high prevalence of cardiac involvement, clinicians should have a high index of suspicion in the attempt to minimize cardiovascular and haemodynamic complications. Valve surgery in patients with antiphospholipid syndrome carries considerable early and late morbidity and mortality, usually caused by thromboembolic and bleeding events. The perioperative anticoagulation management and haemostatic aspect of antiphospholipid syndrome present an exceptional challenges to clinicians, surgeons, anaesthetists and laboratory personnel.