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.

Nonbacterial thrombotic endocarditis of a bioprosthetic valve: Questions to ponder before replacement of the valve.

Nonbacterial thrombotic endocarditis (NBTE) of bioprosthetic valves is extremely rare. We report a 67-year-old lady with early bioprosthetic "failure" that at reoperation was proven to be NBTE. The choice of a prosthesis in this condition may have implications for patients' late clinical course.

Nonbacterial Thrombotic Endocarditis Due to Primary Gallbladder Malignancy with Recurrent Stroke Despite Anticoagulation: Case Report and Literature Review.

Nonbacterial thrombotic endocarditis (NBTE) associated with malignancy is rare; its infrequency and similarity to other diagnoses make it a significant diagnostic challenge. A 63-year-old woman on rivaroxaban for prior deep vein thrombosis presented with left upper extremity weakness and left facial droop with imaging demonstrating multiple strokes. Echocardiograms revealed mitral and aortic valve vegetations. The patient was switched to apixaban and started on vancomycin and ceftriaxone for presumed culture-negative endocarditis. Despite continuing apixaban, her hospital course was complicated by new acute embolic infarcts. Workup confirmed non-mucinous metastatic biliary adenocarcinoma. The patient was placed on a heparin drip then switched to low molecular weight heparin without further embolic events and was discharged to a rehabilitation facility in stable condition with plans for chemotherapy as an outpatient. These clinical, imaging, and histologic findings were consistent with a rare case of NBTE associated with primary non-mucinous gallbladder malignancy complicated by recurrent strokes in which direct oral anticoagulants did not provide adequate anticoagulation.

Nonbacterial thrombotic endocarditis as the initial presentation of prostate cancer- a case report.

Nonbacterial thrombotic endocarditis (NBTE) refers to noninfectious vegetations of the heart valves. It is commonly associated with malignancy and autoimmune diseases like systemic lupus erythematosus, Rheumatoid arthritis. Herein, we present Non-bacterial thrombotic endocarditis and Disseminated intravascular coagulation as the initial manifestations of prostate cancer. A 50-yearold gentleman, known case of hypertension and diabetes, presented with a history of recurrent ischaemic strokes, STEMI and a recent diagnosis of infective endocarditis. He had been taking antibiotics for the past 20 days without any improvement. Negative blood cultures in the presence of vegetations on repeat echocardiography led to a suspicion of NBTE. Laboratory investigations were suggestive of Disseminated intravascular coagulation. CT abdomen and pelvis demonstrated enlarged prostate with enlarged pelvic lymph nodes. Prostate specific antigen was raised at more than 100ng/ml. A bone scan showed extensive metastasis. The patient was started on GnRH analogue and bicalutamide. His Disseminated intravascular coagulation resolved and he was subsequently started on anticoagulants. The valvular lesions diminished without any residual dysfunction.

Nonbacterial Thrombotic Endocarditis Presenting with Leg Pain and a Left Atrial Mass Lesion.

Systemic lupus erythematosus (SLE) is a major cause of nonbacterial thrombotic endocarditis (NBTE) associated with intracardiac sterile vegetations. It is rare for vegetations to present as an atrial tumor. This report describes a 48-year-old female with SLE and antiphospholipid syndrome complicated by recurrent thrombosis on anticoagulation. A large left atrial mass lesion was detected on echocardiography during a work-up for leg burning. Infective endocarditis could not be confirmed, and hence left atrial mass lesion was the most likely diagnosis. The patient was managed surgically and the pathology report revealed fibrin networks in a pattern similar to that of thrombosis, characteristic of NBTE.

Nonbacterial Thrombotic Endocarditis Complicated by Cerebral Infarction in a Patient with Adenomyosis with High Serum CA125 Level; A Case Report.

We report a case of a 48-year-old woman with multiple cerebral infarctions caused by nonbacterial thrombotic endocarditis (NBTE) because of adenomyosis with high serum carbohydrate antigen (CA)125 level. Transesophageal echocardiography (TEE) showed a vegetation, 4 mm in diameter, adjacent to the anterior leaflet of the mitral valve on day 2. Soluble CA125 level was elevated to 901 U/mL. Intravenous infusion of unfractionated heparin sodium was started. On day 35, TEE revealed reduction of the vegetation in size, 2 mm in diameter. On day 38, she was transferred to the hospital for further rehabilitation. CA125 is a transmembrane mucin that contributes to the progression of epithelial ovarian cancer. It is important to keep in mind that adenomyosis with abnormally high serum CA125 level may be at high risk of NBTE.

Cerebral Infarcts by Nonbacterial Thrombotic Endocarditis Associated with Adenomyosis: A Case Report.

We report a case of multiple embolic cerebral infarcts associated with nonbacterial thrombotic endocarditis (NBTE) in a patient with adenomyosis. The patient presented with dysarthria, left perioral sensory change, and left-hand weakness. Magnetic resonance imaging revealed multiple vascular territory infarctions involving the bilateral cerebellum and the right precentral gyrus. Magnetic resonance angiography was normal. d-Dimer, carbohydrate antigen (CA) 19-9, and CA125 levels were elevated. Abdominal and pelvic computed tomography with iodine contrast enhancement revealed a huge adenomyosis with left ovarian cyst. Transesophageal echocardiography (TEE) with agitated saline injection test demonstrated shaggy vegetation at the coapting edge of both mitral leaflets and mitral regurgitation. A diagnosis of NBTE was established and treatment with anticoagulation was initiated. Two weeks later, the thrombi reduced significantly on follow-up TEE and transthoracic echocardiography. The patient underwent an abdominal hysterectomy with bilateral salpingo-oophorectomy, and pathological specimens confirmed adenomyosis. The possibility that adenomyosis can be associated with NBTE suggests one of the underlying thromboembolic mechanisms in adenomyosis. Clinicians should be aware of the potential thromboembolic risk of adenomyosis. Further reporting of similar cases is needed to confirm the thromboembolic mechanism.

Multiple Thrombi in the Heart in Trousseau Syndrome Caused by Pancreatic Carcinoma.

A 65-year-old woman presented to our emergency room because of sudden onset of right hemiparesis with severe fatigue. Neurological examination revealed right hemiparesis with right facial numbness and an extensor planter response on the right side.Magnetic resonance imaging with diffusion-weighted imaging revealed multiple highintensity areas in both cerebral hemispheres and the right cerebellum. A diagnosis of acute stage of multiple brain infarctions caused by emboli was made. An abdominal computed tomography showed a pancreatic tumor with multiple liver metastases. High D-dimer and serum carbohydrate antigen 19-9 concentration strongly suggested Trousseau syndrome associated with pancreatic cancer. The patient had another large embolic stroke and died on day 47. Autopsy was performed. There were large thrombi in the left ventricular apex and in the left atrial appendage There was also a papillary-shaped vegetation on the aortic valve that consisted mainly of fibrin without any inflammatory cells or destruction of the valve, these findings being characteristic of NBTE. This case is remarkable in that the patient had 3 different types of cardiac thrombi in her heart associated with Trousseau syndrome.

Fatal intracranial hemorrhage after intravenous thrombolytic therapy for acute ischemic stroke associated with cancer-related nonbacterial thrombotic endocarditis.

Nonbacterial thrombotic endocarditis (NBTE) is associated with hypercoagulability in patients with inflammatory states such as cancer and autoimmune diseases. Cardiac vegetations caused by NBTE often lead to life-threatening systemic thromboembolism that most frequently affects the brain, spleen, and kidneys. A 54-year-old woman diagnosed with ovarian cancer suddenly developed back pain and left hemiparesis. Although intravenous alteplase (rt-PA) therapy was administered to treat hyperacute ischemic infarction detected by magnetic resonance imaging, intracranial hemorrhage occurred in the left hemisphere several hours later as the patient started to lose consciousness. Transthoracic echocardiography then detected aseptic vegetations on the mitral and aortic valves, indicating NBTE associated with ovarian cancer. Because therapies for NBTE are limited to heparinization and control of underlying diseases, thrombolytic therapy for acute embolic stroke in NBTE has not yet been validated. We postulated that thrombolytic therapy for cancer-related NBTE might easily cause hemorrhagic complications because cancer-related NBTE is often similar to the state of disseminated intravascular coagulation.

Mitral valve surgery for marantic endocarditis and multiple cerebral embolisation.

Valvular involvement is common in antiphospholipid syndrome (APS) with increased risk of thrombo-embolic events. We report a patient with APS and multiple cerebral infarcts. Echocardiography demonstrated verrucous vegetations of the mitral valve in keeping with marantic endocarditis. The patient underwent successful mitral valve replacement. Post-operative clinical and echocardiographic follow-up showed excellent short term results.

Nonbacterial thrombotic endocarditis in pancreatic cancer.

Nonbacterial thrombotic endocarditis (NBTE), known as marantic endocarditis, is a phenomenon due to hypercoagulability with a complex pathogenesis. Originally described by Ziegler, the lesions of NBTE were considered to be fibrin thrombi deposited on normal or superficially degenerated cardiac valves. Numerous reports have identified the relationship between NBTE and a variety of different inflammatory states, including chronic diseases like malignancy and autoimmune disease. NBTE is a serious manifestation of prothtombotic state that is characterized by the deposition of thrombi on previously undamaged heart valves in the absence of a bloodstream bacterial infection and by the increased frequency of arterial embolic events in patients with chronic debilitating diseases. Although hypercoagulability is often seen in patients with pancreatic cancer, NBTE has rarely been reported antemortem. We report a case of marantic endocarditis in patient with pancreatic cancer, in which neurological symptoms preceded the diagnosis of pancreatic cancer.

[Libman-Sacks endocarditis associated with antiphospholipid syndrome. Report of one case]. / Accidente cerebrovascular embólico por endocarditis de Libman-Sacks como manifestación inicial de síndrome antifosfolípidos primario en una paciente de 17 años.

Libman-Sacks endocarditis is a non-infectious valvular damage associated with autoimmune disorders such as Systemic Lupus Erythematosus and Antiphospholipid Syndrome. We report a 17-year-old female consulting in the emergency room due to a right hemiparesis and aphasia. A magnetic resonance imaging showed multiple infarctions in the territory of the left middle cerebral artery, presumably of embolic origin. A trans-esophageal echocardiogram showed a vegetation in the mitral valve. Blood cultures were negative. Antinuclear antibodies and serological tests for antiphospholipid syndrome were positive. Oral anticoagulation was started and the patient was discharged. After six months of follow up, antiphospholipid antibodies are still positive.

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.

Mitral valve Libman-Sacks endocarditis visualized by real time three-dimensional transesophageal echocardiography.

Libman-Sacks endocarditis (LSE) is a common manifestation of valve disease in antiphospholipid syndrome. Mitral valve LSE is characterized by verrucous vegetations on the atrial surfaces of valve leaflets. In this report, mitral valve LSE was visualized by real time 3D transesophageal echocardiography (TEE). 3D TEE provides a unique en face view of the mitral valve akin to a surgical or autopsy view that allows for an accurate determination of the size, shape, and location of the vegetations.

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.

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.