[Hemoglobin drop after thrombolytic therapy in a 57-year-old stroke patient with "erosive gastritis"]. / Hämoglobinabfall nach einer Thrombolysetherapie bei einer 57-jährigen Patientin mit Schlaganfall und "erosiver Gastritis".

A 57-year-old woman underwent esophagogastroduodenoscopy due to a continuous drop in hemoglobin levels reaching 7.4 g/dl after treatment with intravenous thrombolytic therapy 1 week earlier because of an ischemic insult. Numerous erosive lesions were found in the gastric corpus. Histological staining of a specimen from the gastric lesions revealed a poorly differentiated adenocarcinoma. Immunohistochemical examination confirmed the diagnosis of gastric metastasis from lung cancer based on positive staining for thyroid transcriptional factor­1 (TTF-1) and cytokeratin 7 (CK7) as well as via negative staining for caudal-type homeobox­2 (CDX-2). Chest computed tomography demonstrated a mediastinal mass, measuring 3.2 cm and involving the cervical and supraclavicular lymph nodes. A lymph node was subsequently extirpated. Immunohistochemical examination confirmed the diagnosis of lymph node metastasis from lung cancer by positive staining for TTF­1 and CK7. Symptomatic gastric metastasis from lung cancer is an extremely rare clinical entity. Transesophageal echocardiography detected a mass measuring 1.6 cm at the mitral valve with pericardial effusion. On the basis of the echocardiographic findings, a malignant origin was suggested after exclusion of infectious endocarditis. We assumed that the multiple organ infarctions (spleen, kidney, and brain) and gastric hematogenous metastasis must have been caused by disseminated arterial tumor embolism from the intracardiac metastasis. The patient was treated palliatively and died.

Cancer and Cerebrovascular Disease.

PURPOSE OF REVIEW: To review the latest information about the interactions between cancer and cerebrovascular disease. RECENT FINDINGS: Additional data support the finding that both ischemic and hemorrhagic stroke are important complications of cancer or its treatment. Reperfusion therapy is being given successfully to patients with stroke complicating cancer. Hemorrhagic stroke may occur with metastatic disease to the brain, coagulopathies from cancer, in particular leukemia, or as complications of chemotherapy. Ischemic stroke also may be a complication of metastatic disease with local invasion of vessels, a pro-thrombotic disorder such as non-bacterial thrombotic endocarditis (NBTE) or disseminated intravascular coagulation (DIC), or secondary to chemotherapy. Stroke also is a potential consequence of radiation therapy to the head and neck. Venous sinus thrombosis may develop with hematologic malignancies or chemotherapy. Although many patients will have a history of cancer at the time of stroke, a cerebrovascular event may be the initial manifestation of a malignancy.

Pathology of the Aortic Valve: Aortic Valve Stenosis/Aortic Regurgitation.

PURPOSE OF REVIEW: This discussion is intended to review the anatomy and pathology of the aortic valve and aortic root region, and to provide a basis for the understanding of and treatment of the important life-threatening diseases that affect the aortic valve. RECENT FINDINGS: The most exciting recent finding is that less invasive methods are being developed to treat diseases of the aortic valve. There are no medical cures for aortic valve diseases. Until recently, open-heart surgery was the only effective method of treatment. Now percutaneous approaches to implant bioprosthetic valves into failed native or previously implanted bioprosthetic valves are being developed and utilized. A genetic basis for many of the diseases that affect the aortic valve is being discovered that also should lead to innovative approaches to perhaps prevent these disease. Sequencing of ribosomal RNA is assisting in identifying organisms causing endocarditis, leading to more effective antimicrobial therapy. There is exciting, expanding, therapeutic innovation in the treatment of aortic valve disease.

An Uncommon Cause of Stroke: Non-bacterial Thrombotic Endocarditis.

Our objective is to present the case of an uncommon but probably under-recognized cause of stroke: Non-bacterial thrombotic endocarditis (NBTE). A 59-year-old man presented to our hospital with multiple bihemispheric infarcts despite taking rivaroxaban for pulmonary emboli diagnosed 2 weeks earlier. The patient's symptoms progressed quickly and he died within a week of his initial presentation despite attempts at neuroradiologically guided clot retrieval and early recognition and treatment of disseminated intravascular coagulation. On postmortem examination it was discovered that he had an undiagnosed squamous cell adenocarcinoma of the lung and NBTE. NBTE is difficult to diagnose and difficult to treat. It is associated with a mortality rate and is often not diagnosed until autopsy. However there are case reports in the literature where NBTE has been successfully treated. Early recognition and prompt treatment of the underlying disease process is the essential first step.

[Non-bacterial thrombotic endocarditis on the bicuspid aortic valve in a 25-year-old male with lupus anticoagulant]. / Niebakteryjne zakrzepowe zapalenie wsierdzia na dwuplatkowej zastawce aortalnej u 25-letniego mezczyzny z antykoagulantem toczniowym.

Non-bacterial thrombotic endocarditis (NBTE) is characterized by presence of sterile vegetations that develop from fibrin and platelets on heart valves. The main conditions predisposing to NBTE are malignancy, autoimmune diseases and other hypercoagulable states. The authors describe a case of a 25-year-old male, in whom NBTE was diagnosed on the bicuspid aortic valve. The presence of significant aortic regurgitation and dental caries were initially suggestive of infective endocarditis; although, serial blood culture were negative and procalcytonin concentration was within normal ranges. Empiric antibiotic therapy did not result in diminishing of vegetations, similarly to the anticoagulation treatment initiated when strongly positive lupus anticoagulant was detected in laboratory findings. Aortic valve replacement was necessary. Bacteriologic examination of the excised valve was negative. Widespread fibrin masses at different stages of organization on the leaflets confirmed NBTE in histopathologic assessment. Lupus anticoagulant was probably secondary to thyroid autoimmune disease.

Echocardiographic findings in cancer-associated non-bacterial thrombotic endocarditis: clinical series of 111 patients from a single institution.

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.

Exploring the Complexities of Non-Bacterial Thrombotic Endocarditis: Highlights from Literature and Case Studies.

Non-bacterial thrombotic endocarditis (NBTE) is a form of non-infective endocarditis characterized by the deposition of sterile fibrin and platelets on cardiac valves. Even though some studies have identified important pathophysiological features, many aspects remain poorly understood. Given its wide availability, transthoracic echocardiography is typically the initial diagnostic approach to the patient. Additionally, recent technological advancements in transesophageal echocardiography, such as three-dimensional and multiplanar reconstruction analysis, have significantly improved diagnostic accuracy over time. By presenting our case series and performing a literature review, we focused on the main pathophysiologic, diagnostic, and therapeutic aspects of this rare but potentially life-threatening disease.

Incidentally Discovered Endocarditis Leading to the Diagnosis of an Epidermal Growth Factor Receptor Mutant Metastatic Pulmonary Malignancy of Occult Primary Tumor.

Introduction: Non-bacterial thrombotic endocarditis is well documented in the literature to occur in patients with known malignancies. It is, however, much less common for patients to be diagnosed with marantic endocarditis as the presenting sign of an unknown primary malignancy. Case Presentation: We discuss a case in which a patient was undergoing routine surveillance for his known heart failure with a transthoracic echocardiogram when an aortic valve vegetation was discovered. After further investigation, he was found to have metastatic adenocarcinoma of the lung. Next-generation sequencing was utilized to identify an EGFR mutation, which led to the patient being treated with osimertinib. Conclusion: Adequate treatment of his primary malignancy, along with anticoagulation, led to overall clinical improvement of the patient.

Nonbacterial thrombotic endocarditis of mitral valve associated with a lymphoproliferative malignancy: case report and literature review.

BACKGROUND: Non-bacterial thrombotic endocarditis (NBTE) is a rare condition marked by sterile vegetations on cardiac valves, often linked to rheumatologic diseases, autoimmune disorders, and advanced solid malignancies. An early diagnosis and treatment of the associated clinical condition are mandatory, although they do not usually eliminate valvular vegetations, making anticoagulation essential to prevent embolic events. Despite variability, the prognosis of NBTE is usually unfavorable due to recurrent embolic events and the severity of the primary condition, typically advanced cancer. CASE PRESENTATION: We present a case of a 57 years-old male who presented to the emergency department with a 5-day history of painful bilateral digital edema and color change episodes (from pallor to cyanosis). Physical examination revealed erythrocyanosis in the distal extremities, prompting consideration of secondary Raynaud syndrome. Despite medical therapy, progressive digital ischemia led to multiple finger amputations. During etiological investigation, anticoagulation tests and autoimmune analysis yielded negative results. A transesophageal echocardiogram was performed, revealing an irregular hyperechogenic mass on the anterior leaflet of the mitral valve without valve dysfunction, and a thoracic computed tomography scan with contrast showed an enlarged right paratracheal lymph node. Histopathological analysis from a transthoracic needle biopsy of the paratracheal lymph node revealed diffuse large B-cell lymphoma. The patient underwent aggressive R-CHOP chemotherapy, achieving a favorable complete response. CONCLUSION: This is a particular case involving the occurrence of NBTE and Raynaud phenomenon as the initial paraneoplastic manifestations in a previously healthy young man. Reports of NBTE associated with lymphoproliferative conditions are quite rare, with fewer than ten cases described in the literature. To our knowledge, this is the first case of NBTE specifically associated with diffuse large B-cell lymphoma.

Non-bacterial Thrombotic Endocarditis (NBTE) in the Absence of Malignancy or Lupus Anticoagulant/Antiphospholipid Antibodies: A Case Report.

Non-bacterial thrombotic endocarditis (NBTE) is a very rare condition characterized by sterile thrombi formation on cardiac valves and is often associated with hypercoagulation states, such as malignancy and autoimmune disorders. We present the case of a 74-year-old patient admitted to the intensive care unit with acute respiratory failure, who had a history of COVID-19 infection five months prior to admission, despite having received certified vaccination. The patient developed NBTE involving the mitral valve, alongside acute respiratory distress syndrome (ARDS). In spite of the exclusion of cancer and systemic connective tissue disorders, the patient's condition rapidly deteriorated, leading to treatment-resistant multi-organ failure and demise, despite aggressive management, including anticoagulation therapy, mechanical ventilation, and renal replacement therapy. This case underscores the need for further research into the mechanisms underlying NBTE in the absence of traditional risk factors. Additionally, it highlights the importance of long-term anticoagulant therapy in NBTE management to mitigate the risk of embolic complications. Our case contributes to the growing body of literature identifying a subset of NBTE cancer-free patients with distinct characteristics, including those associated with current or past COVID-19 infection.

Nonbacterial Thrombotic Endocarditis Presenting as a Mass in the Right Atrium Diagnosed by Open Chest Surgery: A Case Report.

Nonbacterial thrombotic endocarditis (NBTE) is a condition that results in the development of vegetation on cardiac valves that are devoid of inflammation and bacteria. We herein report a 60-year-old man who transferred to our hospital because of a systemic embolism and heart failure. A mass in the right atrium and vegetation on the mitral valve were observed. He was first diagnosed with infectious endocarditis according to the Duke criteria. During treatment, however, the patient was diagnosed with antiphospholipid syndrome and cancer. After four weeks of antibacterial therapy, the patient underwent open chest surgery, and the postoperative histological diagnosis was NBTE.

Unveiling Lung Adenocarcinoma: Non-bacterial Thrombotic Endocarditis as the Debut Sign.

Non-bacterial thrombotic endocarditis (NBTE) involves the deposition of fibrin and platelets on heart valves, frequently leading to systemic embolism. The association between NBTE and cancer demands thorough investigation in cases lacking an evident cause. This case report elucidates the clinical course of a nonsmoking woman in her sixties with NBTE linked to pulmonary adenocarcinoma. The patient, who had a history of multiple sclerosis (MS) and was receiving dimethyl fumarate treatment, presented to the emergency department with stroke-like symptoms. Diagnostic challenges arose due to preexisting motor sensory impairment from MS. Initial evaluations revealed hypocapnia and elevated inflammatory markers. Blood cultures were obtained twice, and imaging confirmed pneumonia, left pleural effusion, and chronic pulmonary embolism while excluding acute vascular events or intracranial hemorrhage. The first transthoracic echocardiogram (TTE) indicated no cardiac abnormalities. Treatment encompassed parenteral antibiotics, systemic anticoagulation, and admission to medical floors. Although the initial treatment yielded a positive clinical response, subsequent complications emerged. On the tenth day, the patient required additional interventions, including broad-spectrum antibiotics and supplemental oxygen. A follow-up chest X-ray revealed persistent pneumonia and pleural effusion, and blood cultures upon admission returned negative. A subsequent head MRI confirmed an embolic stroke and displayed evidence of MS progression. Around the twentieth day, empirical treatment for infective endocarditis was initiated, and an 8 mm vegetation on the aortic valve was identified via transesophageal echocardiography (TOE). Acute pulmonary edema prompted a transfer to the intermediate care unit. Further investigations, including left thoracocentesis and CT, unveiled exudate and metastatic lesions in the liver, ilium, and kidney. Unfortunately, on the twenty-fifth day, the patient experienced acute myocardial infarction, right leg ischemia, disseminated intravascular coagulation, and shock. Pleural fluid analysis revealed malignant cells suggestive of lung adenocarcinoma. This case underscores the pivotal role of timely NBTE recognition and the search for malignancy when workup for infective endocarditis and autoimmune panels is negative. Moreover, it emphasizes the significance of vigilant monitoring, particularly in immunocompromised individuals or those with preexisting neurological deficits, especially when new neurological symptoms manifest. These insights significantly contribute to the comprehension of NBTE management and its implications for analogous patient cohorts.

Nonbacterial Thrombotic Endocarditis With Embolic Phenomena Diagnosed by Transesophageal Echocardiogram.

Nonbacterial thrombotic endocarditis (NBTE) is a valvular disorder commonly associated with malignancy and connective tissue diseases. While the disorder is often discovered during autopsy, it is sometimes diagnosed in patients who present with systemic embolization. Here, we discuss the case of a 52-year-old female, with connective tissue disease and malignancy, who presented with symptoms of systemic embolization and was diagnosed with NBTE by transesophageal echocardiogram (TEE). This case highlights the utility of TEE in diagnosing NBTE and its influence in guiding the subsequent management of patients.

Non-bacterial Thrombotic Endocarditis Related to Squamous Cell Carcinoma of the Cervix.

We report the case of a 51-year-old woman who presented with multiple thrombotic events, including deep vein thrombosis, extensive pulmonary embolisms, myocardial infarction, and multiple ischemic strokes suggesting cardiogenic embolization. Recent history was significant for locally advanced squamous cell carcinoma of the cervix. Echocardiogram revealed large aortic valve vegetations in the absence of evidence of infectious endocarditis consistent with the diagnosis of non-bacterial thrombotic endocarditis (NBTE). This case is a rare presentation of NBTE associated with squamous cell carcinoma of the cervix.

Case report: New is not always better: treatment of non-bacterial thrombotic endocarditis.

An elderly female with metastatic adenocarcinoma of the lung and atrial fibrillation presented with multiple embolic strokes while on anticoagulation with Apixaban. After further investigation, a TEE showed lesions of non-bacterial thrombotic endocarditis on the mitral valve. A decision to switch the patient to LMWH for anticoagulation was then made and a follow-up TEE showed resolution of the NBTE. In this abstract, we show that heparin should remain as the anticoagulation agent of choice in the setting of NBTE associated with malignancy.

A Rare Case of Bartonella henselae Infective Endocarditis Causing an Embolic Cerebrovascular Accident.

Bartonella is a facultative intracellular Gram-negative aerobic rod that is an important cause of culture-negative endocarditis that only accounts for 3% of all infective endocarditis (IE) cases. Throughout the literature, there have been very few documented cases of an embolic stroke caused by Bartonella henselae (B. henselae) IE. Following a comprehensive review of the literature, it appears that only a small number of articles have reported on the correlation between cerebrovascular accidents (CVAs) and Bartonella IE. Here, we present a case of a 42-year-old male with a cerebral embolic event as a complication of B. henselae IE.

An Unusual Case of Nonbacterial Thrombotic Endocarditis Attributable to Malignancy.

Nonbacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, is a condition characterized by the deposition of thrombi and fibrin on normal or degenerated cardiac valves in the absence of microorganisms. We report a case of a 60-year-old male with nonbacterial thrombotic endocarditis found on transesophageal echocardiogram (TEE) after a normal TEE just one month prior. Our patient presented with abdominal pain associated with poor appetite and unintentional 20-pound weight loss for one month. Chest computed tomography revealed the presence of a mass-like opacification in the right lung middle lobe with moderate pericardial effusions. A biopsy of the mass confirmed malignancy consistent with lung primary adenocarcinoma. Subsequently, during hospitalization, the patient developed left lower extremity pain. Arterial ultrasound showed occlusion of the distal left popliteal artery for which he underwent thrombectomy of the left superficial femoral artery, balloon angioplasty of the left posterior tibial artery, and left popliteal artery. Repeat TEE during current hospitalization revealed a large 2 cm vegetation on the noncoronary cusp of the aortic valve. Studies for infective endocarditis were unremarkable. Subsequently, he was treated with aortic valve replacement and anticoagulation. After discharge, he returned with bilateral occipital infarcts four days later and expired.

Ross procedure after prosthetic valve thrombosis in a patient with antiphospholipid syndrome and recurrent bleeding.

The Ross procedure allows replacement of a diseased aortic valve with pulmonary root autograft, possibly avoiding the highly thrombotic mechanical valves and immunologic deterioration of tissue valves in antiphospholipid syndrome (APS). Here, we present the use of the Ross procedure in a 42-year-old woman with mild intellectual disability, APS, and a complex anticoagulation history after she presented with thrombosis of her mechanical On-X aortic valve previously implanted for non-bacterial thrombotic endocarditis.

Recurrent embolic strokes due to antiphospholipid syndrome and non-bacterial thrombotic endocarditis in a patient with basal cell carcinoma.

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.

Thrombosis of Chiari's network in the setting of non-bacterial thrombotic endocarditis occurring under non-vitamin K antagonist oral anticoagulation: a case report.

Background: Non-bacterial thrombotic endocarditis (NBTE) is a rare condition characterized by sterile thrombi on undamaged valves. We herein report a case of NBTE involving the Chiari's network and the mitral valve, related to a metastatic cancer, and occurring under non-vitamin K antagonist oral anticoagulant (NOAC). Case summary: A 74-year-old patient with metastatic pulmonary cancer was diagnosed with a right atrium mass during pre-treatment cardiovascular check-up. Transoesophageal echocardiography and cardiac magnetic resonance concluded that the mass was a Chiari's network. Two months later, the patient was admitted for a pulmonary embolism and started rivaroxaban. At 1-month follow-up, the patient underwent a new echocardiography, which showed an increased size of the right atrium mass and the presence of two new masses on the mitral valve. She suffered an ischaemic stroke. Infectious work-up was negative. Coagulation factor VIII was 419%. A NBTE with Chiari's network thrombosis and mitral valve involvement was suspected in the setting of a hypercoagulable state related to the active cancer, and intravenous heparin was started, bridged to vitamin K antagonist (VKA) after 3 weeks. All the lesions were fully resolved on follow-up echocardiography at 6 weeks. Discussion: This case highlights an atypical association of thrombosis on right and left heart chamber with systemic and pulmonary embolism, related to a hypercoagulable state. Chiari's network is an embryonic remnant with no clinical significance and is exceptionally thrombosed. Failure of treatment by NOAC highlights the complexity of cancer-related thrombosis, particularly in NBTE, and the necessity of heparin and VKA in our case.