Marantic Endocarditis in Metastatic Lung Adenocarcinoma.

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.

Trivalvular nonbacterial thrombotic endocarditis in a patient with colon adenocarcinoma: a case report.

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.

Left ventricular free-wall rupture: An unusual presentation of non-bacterial thrombotic endocarditis.

Non-bacterial thrombotic endocarditis (NBTE) is a rare, often asymptomatic, condition. A 55-year-old woman presented with hemiparesis, facial palsy and chest pain. After urgent investigation, she was referred as a case of type A aortic dissection complicated by tamponade, myocardial infarction and stroke. Review of her imaging identified haemopericardium but no dissection, and emergency surgery proceeded considering her unstable condition. She underwent an emergency repair of left-ventricular free-wall rupture and excision of an aortic valve vegetation. Postoperative investigations confirmed a diagnosis of NBTE in the setting of a plexiform neurofibroma, and she was discharged 9 weeks later with residual neurological symptoms. This case poses a previously unreported acute presentation of NBTE and highlights the complexities in its diagnosis and management.

Non-bacterial thrombotic endocarditis: A state-of-the-art contemporary review.

Non-bacterial thrombotic endocarditis (NBTE), also known as Libman-Sacks, marantic, thrombotic, or verrucous endocarditis, is a form of non-infective endocarditis that affects cardiac structures in patients who have predisposing underlying conditions.1 As it is rarely encountered in routine clinical practice, the condition may be overlooked or misdiagnosed. On the other hand, other similar clinical entities might be erroneously labeled as NBTE. Notwithstanding its ostensibly uncommon appearance in clinical practice, our understanding of NBTE has been expanding, especially with the advent of modern and advanced diagnostic tools that facilitate the evaluation process. Herein, we provide a comprehensive review of NBTE, with a focus on the contemporary diagnostic evaluation and management.

A New Insight Into Nonbacterial Thrombotic Endocarditis: A Systematic Review of Cases.

BACKGROUND: Nonbacterial thrombotic endocarditis is characterized by the presence of organized thrombi on cardiac valves, often associated with hypercoagulable states. There is a paucity of data regarding the predictors of mortality in patients with nonbacterial thrombotic endocarditis. Our primary aim was to identify predictors of in-hospital mortality in patients with nonbacterial thrombotic endocarditis. METHODS: A systematic literature review of all published cases and case series was performed until May 2018 according to Preferred Reporting Items for Systematic Review and Meta-analyses statement guidelines. We applied random forest machine learning model to identify predictors of in-patient mortality in patients with nonbacterial thrombotic endocarditis. RESULTS: Our search generated a total of 163 patients (mean age, 46 ± 17 years; women, 69%) with newly diagnosed nonbacterial thrombotic endocarditis. The in-hospital mortality rate in the study cohort was 30%. Among the patients who died in the hospital, initial presentation of pulmonary embolism (12.2 vs. 2.6%), splenic (38.7 vs. 10.5%), and renal (40.8 vs. 9.6%) infarcts were higher compared to patients alive at the time of discharge. Higher rates of malignancy (71.4 vs. 39.4%, P = .0003) and lower rates of antiphospholipid syndrome (8.1 vs. 48.2%, P = .0001) were noted in deceased patients. Random forest machine learning analysis showed that older age, presence of antiphospholipid syndrome, splenic infarct, renal infarct, peripheral thromboembolism, pulmonary embolism, myocardial infarction, and mitral valve regurgitation were significantly associated with increased risk of in-hospital mortality. CONCLUSION: Patients admitted with nonbacterial thrombotic endocarditis have a high rate of in-hospital mortality. Factors including older age, presence of antiphospholipid syndrome, splenic/renal infarct, lower limb thromboembolism, pulmonary embolism, myocardial infarction, and mitral valve regurgitation were significantly associated with increased risk of in-hospital mortality in patients with nonbacterial thrombotic endocarditis.

Atypical Presentation of Marantic Endocarditis.

We describe a 39-year-old man referred for surgical aortic valve replacement for severe symptomatic aortic stenosis. Intraoperative inspection was unexpectedly consistent with marantic endocarditis. Pathology confirmed nonbacterial thrombotic endocarditis. We present high-resolution intraoperative, diagnostic, and pathology images of nonbacterial thrombotic endocarditis in a patient with antiphospholipid syndrome with atypical presentation.

Reversibility of valve regurgitation due to cancer-related non-bacterial thrombotic endocarditis after switching direct oral anticoagulation for heparin.

Non-bacterial thrombotic endocarditis (NBTE) is a rare condition related to a state of hypercoagulability in advanced neoplastic disease. Most of the time, arterial thromboembolic event precedes the diagnosis of NBTE. We report here a case of NBTE responsible for multiple ischaemic strokes, which leads to the diagnosis of metastatic pancreatic adenocarcinoma. Aortic and mitral valvular regurgitations secondary to NBTE appeared within 6 weeks despite therapeutic anticoagulation with direct oral anticoagulant (DOAC) in stroke prevention of paroxysmal atrial fibrillation. Bivalvular regurgitations resolved 8 weeks after therapeutic switch to low-molecular-weight heparin (LMWH) and chemotherapy. DOACs are a possible alternative to LMWH for the prevention of venous thromboembolism in patients with active neoplasia. There is a lack of evidence for a clinical efficiency for the prevention of arterial thromboembolism in NBTE. We propose here a short review of the efficacy of anticoagulant therapy for the prevention of arterial thromboembolism in NBTE.

Non-bacterial thrombotic endocarditis and metastatic lung adenocarcinoma.

A 69-year-old Chinese man presented with exertional dyspnoea and subjective left upper limb weakness. Initial clinical impressions were community-acquired pneumonia and cerebrovascular accident. Further imaging studies revealed an incidental mitral valve vegetation and left lung upper lobe nodule likely a lung malignancy with possible lymphangitis carcinomatosis. Appropriate empirical antibiotic treatment for infective endocarditis was instituted early in admission, but multiple blood cultures were negative. The patient progressively developed worsening neurological dysfunction and subconjunctival haemorrhage from recurrent embolic complications despite empirical antimicrobial treatment. Histology finally revealed lung adenocarcinoma after delay in obtaining biopsy due to high procedural risk from recurrent stroke. Unfortunately, before the patient could undergo any systemic oncology treatment, he deteriorated with type I respiratory failure from obstructive pneumonia and eventually demised. Important lessons include the need to consider non-bacterial thrombotic endocarditis as a differential in the appropriate clinical context followed by anticoagulation with systemic treatment as early as possible.

Non-bacterial thrombotic endocarditis and coronary thrombectomy in a patient with metastatic small cell lung carcinoma.

A 66-year-old Caucasian man was initially admitted with a metastatic small cell lung carcinoma, hyponatraemia and obstructive pneumonia. His transthoracic echocardiogram (TTE) was normal. Ten days after admission, he was diagnosed with a non-ST segment elevation myocardial infarction (MI). Both a repeated TTE and a transoesophageal echocardiogram identified thickened, myxomatous mitral valve leaflet tips with small, mobile masses identified as vegetations, and new, eccentric, severe mitral regurgitation. Subsequent cardiac catheterisation recorded thrombotic occlusion of the right coronary artery. Successful coronary thrombectomy was carried out, but the patient died. A diagnosis of non-bacterial thrombotic endocarditis leading to coronary embolisation and MI was made. The clinical course and treatment choices are discussed.

A Contemporary 20-Year Cleveland Clinic Experience of Nonbacterial Thrombotic Endocarditis: Etiology, Echocardiographic Imaging, Management, and Outcomes.

BACKGROUND: Nonbacterial thrombotic endocarditis, or marantic endocarditis, is rare. Contemporary data on the etiology, echocardiographic evaluation, and management of nonbacterial thrombotic endocarditis are limited. METHODS: A single-center retrospective cohort study was performed. Electronic medical records and echocardiographic records were searched for patients ages ≥18 years with a confirmed diagnosis of nonbacterial thrombotic endocarditis between January 1999 and November 2019. Demographic, echocardiographic, and management data were collected. RESULTS: Of 600,577 transthoracic echocardiograms (TTEs) and 89,264 transesophageal echocardiograms (TEEs), 42 patients had nonbacterial thrombotic endocarditis (mean age: 54 ± 14.5 years; 66.7% were female). The median duration of follow-up was 8.2 (interquartile range 3.3-24.4) months. Seventeen patients (40.5%) had malignancy, 33.3% had systemic lupus erythematosus, and 35.7% had antiphospholipid antibody syndrome. Stroke was the most common presentation (59.5%). TTE enabled the diagnosis in 19 cases (45.2%), compared with TEE, which identified the condition in 33 of 34 (97.1%) cases in which it was utilized. Three-dimensional echocardiography was performed in 17 TEEs. The most common valves involved were mitral (61.9%), and aortic (23.8%) valves. Thirty-two patients were managed with anticoagulation. Ten patients underwent surgery. Sixteen (38.1%) patients died, most of whom had a diagnosis of advanced malignancy. CONCLUSION: In a contemporary 20-year cohort, TTE and TEE played important roles in diagnosis, with superior diagnostic performance of TEE for nonbacterial thrombotic endocarditis. Mortality was high, and advanced malignancy portended a worse prognosis. Management in most cases was therapeutic anticoagulation. In select cases, surgery provided favorable outcomes.

Non-bacterial thrombotic endocarditis: a rare presentation and literature review.

A 66-year-old woman with a remote history of breast cancer and prior tobacco use presented to the hospital with chest pain. She was found to have an elevated troponin consistent with a diagnosis of a non-ST segment elevation myocardial infarction (NSTEMI). A left heart catheterisation revealed non-obstructive coronary disease, and subsequent transthoracic and transoesophageal echocardiograms demonstrated vegetations on both the mitral and aortic valves. Multiple blood cultures showed no growth raising suspicion for non-bacterial thrombotic endocarditis (NBTE). A CT of the chest, abdomen and pelvis was obtained that was consistent with metastatic pancreatic cancer. Her hospital course was complicated by recurrent embolic strokes leading to a rapid clinical deterioration. As a result, she was transitioned to comfort measures and passed away shortly thereafter. To our knowledge, this is the first reported case of an NSTEMI as the initial presentation of NBTE due to underlying malignancy.