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Ntaios G, Baumgartner H, Doehner W, Donal E, Edvardsen T, Healey JS, Iung B, Kamel H, Kasner SE, Korompoki E, Navi BB, Pristipino C, Saba L, Schnabel RB, Svennberg E, Lip GYH. Embolic strokes of undetermined source: a clinical consensus statement of the ESC Council on Stroke, the European Association of Cardiovascular Imaging and the European Heart Rhythm Association of the ESC. Eur Heart J 2024; 45:1701-1715. [PMID: 38685132 PMCID: PMC11107123 DOI: 10.1093/eurheartj/ehae150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
One in six ischaemic stroke patients has an embolic stroke of undetermined source (ESUS), defined as a stroke with unclear aetiology despite recommended diagnostic evaluation. The overall cardiovascular risk of ESUS is high and it is important to optimize strategies to prevent recurrent stroke and other cardiovascular events. The aim of clinicians when confronted with a patient not only with ESUS but also with any other medical condition of unclear aetiology is to identify the actual cause amongst a list of potential differential diagnoses, in order to optimize secondary prevention. However, specifically in ESUS, this may be challenging as multiple potential thromboembolic sources frequently coexist. Also, it can be delusively reassuring because despite the implementation of specific treatments for the individual pathology presumed to be the actual thromboembolic source, patients can still be vulnerable to stroke and other cardiovascular events caused by other pathologies already identified during the index diagnostic evaluation but whose thromboembolic potential was underestimated. Therefore, rather than trying to presume which particular mechanism is the actual embolic source in an ESUS patient, it is important to assess the overall thromboembolic risk of the patient through synthesis of the individual risks linked to all pathologies present, regardless if presumed causally associated or not. In this paper, a multi-disciplinary panel of clinicians/researchers from various backgrounds of expertise and specialties (cardiology, internal medicine, neurology, radiology and vascular surgery) proposes a comprehensive multi-dimensional assessment of the overall thromboembolic risk in ESUS patients through the composition of individual risks associated with all prevalent pathologies.
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Affiliation(s)
- George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Larissa 41132, Greece
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Wolfram Doehner
- Department of Cardiology (Campus Virchow), Center of Stroke Research Berlin, German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin Institute of Health-Center for Regenerative Therapies, Deutsches Herzzentrum der Charité, Charité, Berlin, Germany
| | - Erwan Donal
- Service de Cardiologie et CIC-IT 1414, CHU Rennes, Rennes, France
| | - Thor Edvardsen
- Department of Cardiology, Faculty of Medicine, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway
| | - Jeff S Healey
- Cardiology Division, McMaster University, Hamilton, Canada
| | - Bernard Iung
- Bichat Hospital, APHP and Université Paris-Cité, INSERM LVTS U1148, Paris, France
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Scott E Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eleni Korompoki
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian Pristipino
- Interventional and Intensive Cardiology Unit, San Filippo Neri Hospital, ASL Roma 1, Rome, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari—Polo di Monserrato, Cagliari, Italy
| | - Renate B Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany
| | - Emma Svennberg
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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2
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Zong X, Wang X, Liu S, Tang X, Zheng D. Isolated distal deep vein thrombosis associated with adenomyosis: Case report and literature review. Clin Case Rep 2024; 12:e8859. [PMID: 38725929 PMCID: PMC11079546 DOI: 10.1002/ccr3.8859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 04/17/2024] [Accepted: 04/19/2024] [Indexed: 05/12/2024] Open
Abstract
While adenomyosis is commonly associated with a mild risk of thrombotic complications, the presence of additional thrombophilia factors can increase this risk, particularly in individuals with severe symptoms and elevated CA125 levels.
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Affiliation(s)
- Xiaolong Zong
- Department of Clinical LaboratoryThe Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Xuechao Wang
- Department of Clinical Laboratory, Tianjin Baodi HospitalBaodi Clinical College of Tianjin Medical UniversityTianjinChina
| | - Shenjia Liu
- Department of UltrasoundThe Second Hospital of Tianjin Medical UniversityTianjinChina
| | - Xuemei Tang
- Department of Clinical LaboratoryZhouqu People's Hospital, Gannan Tibetan Autonomous PrefectureGansu ProvinceChina
| | - Dayong Zheng
- Department of Clinical Laboratory, Tianjin Baodi HospitalBaodi Clinical College of Tianjin Medical UniversityTianjinChina
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3
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Duarte F, Barradas MI, Dias AR, Faria C, Machado C, Pavão C. Nonbacterial thrombotic endocarditis of mitral valve associated with a lymphoproliferative malignancy: case report and literature review. CARDIO-ONCOLOGY (LONDON, ENGLAND) 2024; 10:25. [PMID: 38641628 PMCID: PMC11027228 DOI: 10.1186/s40959-024-00226-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 04/02/2024] [Indexed: 04/21/2024]
Abstract
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.
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Affiliation(s)
- Fabiana Duarte
- Cardiology Department, Hospital of Divino Espírito Santo of Ponta Delgada, Avenida D. Manuel I 9500-370, São Miguel Island, Azores, Portugal.
| | - Maria Inês Barradas
- Cardiology Department, Hospital of Divino Espírito Santo of Ponta Delgada, Avenida D. Manuel I 9500-370, São Miguel Island, Azores, Portugal
| | - Ana Raquel Dias
- Hematology Department, Hospital of Divino Espírito Santo of Ponta Delgada, São Miguel Island, Azores, Portugal
| | - Carlos Faria
- Anatomical Pathology Department, Hospital of Divino Espírito Santo of Ponta Delgada, São Miguel Island, Azores, Portugal
| | - Carina Machado
- Cardiology Department, Hospital of Divino Espírito Santo of Ponta Delgada, Avenida D. Manuel I 9500-370, São Miguel Island, Azores, Portugal
| | - Carolina Pavão
- Hematology Department, Hospital of Divino Espírito Santo of Ponta Delgada, São Miguel Island, Azores, Portugal
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Motiduki N, Ushioda R, Yuzawa S, Miyatani K, Isa H, Setogawa Y, Ishidou K, Narita M, Suzuki F, Hirofuji A, Okubo R, Kunioka S, Tsutsui M, Ishikawa N, Hiroyuki K. A case of non-bacterial thrombotic endocarditis on the aortic valve following coronary angiography. J Surg Case Rep 2024; 2024:rjae212. [PMID: 38572290 PMCID: PMC10989293 DOI: 10.1093/jscr/rjae212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/15/2024] [Indexed: 04/05/2024] Open
Abstract
Nonbacterial thrombotic endocarditis (NBTE) on the aortic valve involves fibrin and platelet aggregate formation, potentially leading to embolic events. We present a case of NBTE on the aortic valve following coronary angiography (CAG) in a 54-year-old man with multiple comorbidities. Surgical thrombectomy was performed owing to acute cerebral infarcts. This case highlights the significance of considering that mechanical trauma from catheterization during CAG can trigger thrombus formation.
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Affiliation(s)
- Nobuhiro Motiduki
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
| | - Ryohei Ushioda
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
| | - Sayaka Yuzawa
- Department of Diagnostic Pathology, Asahikawa Medical University Hospital, Midorigaoka 1-1-1, Asahikawa 078-8510, Japan
| | - Kazuki Miyatani
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
| | - Hideki Isa
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
| | - Yuki Setogawa
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
| | - Kohei Ishidou
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
| | - Masahiko Narita
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
| | - Fumitaka Suzuki
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
| | - Aina Hirofuji
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
| | - Ryo Okubo
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
| | - Shingo Kunioka
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
| | - Masahiro Tsutsui
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
| | - Natsuya Ishikawa
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
| | - Kamiya Hiroyuki
- Department of Cardiac Surgery, Asahikawa Medical University, Midorigaoka Higashi 2-1-1-1, Asahikawa 078-8510, Japan
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5
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Tisch C, Ernst D, Falke M, Speicher P, Ziaka M. Systemic embolization due to non-bacterial thrombotic endocarditis: An autopsy case report and mini review of the literature. SAGE Open Med Case Rep 2024; 12:2050313X241229576. [PMID: 38292877 PMCID: PMC10826374 DOI: 10.1177/2050313x241229576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/12/2024] [Indexed: 02/01/2024] Open
Abstract
Nonbacterial thrombotic endocarditis is a rare, non-infectious complication associated with hypercoagulable states, such as malignancies and autoimmune diseases. Due to the difficulty distinguishing marantic endocarditis from infective endocarditis, the diagnosis is often delayed or even a postmortem finding. We present the case of a 70-year-old Caucasian female with marantic endocarditis secondary to metastatic duodenal adenocarcinoma. The patient presented with a short history of memory deficits, personality disturbances, and left homonymous hemianopia. Diffusion-weighted magnetic resonance imaging showed multi-territorial bihemispheric cerebral infarctions. Transthoracic echocardiography revealed native mitral valve endocarditis, and serial blood cultures remained negative. Despite antibiotic therapy, the patient's condition continuously deteriorated, and she died within 3 weeks after her initial presentation. Postmortem examination showed a non-bacterial thrombotic endocarditis. Early clinical suspicion and prompt diagnosis are of decisive importance for the survival of the patients.
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Affiliation(s)
- Carmen Tisch
- Department of Internal Medicine, Hospital of Thun, Thun, Switzerland
| | - Daniel Ernst
- Department of Internal Medicine, Hospital of Thun, Thun, Switzerland
| | - Monika Falke
- University of Bern, Institute of Tissue Medicine and Pathology, Bern, Switzerland
| | - Philip Speicher
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mairi Ziaka
- Department of Internal Medicine, Hospital of Thun, Thun, Switzerland
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6
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Nagao T, Sakamoto A, Fujihiro M, Kawakami R, Suwa K, Hattori K, Ohtani H, Saotome M, Baba S, V Finn A, Maekawa Y. Nonbacterial Thrombotic Endocarditis Caused by Early-stage Lung Cancer: An Autopsy Case Report. Intern Med 2024; 63:87-92. [PMID: 37164662 PMCID: PMC10824638 DOI: 10.2169/internalmedicine.2004-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 03/30/2023] [Indexed: 05/12/2023] Open
Abstract
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.
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Affiliation(s)
- Tomoaki Nagao
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Atsushi Sakamoto
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Mayu Fujihiro
- Department of Diagnostic Pathology, Hamamatsu University School of Medicine, Japan
| | | | - Kenichiro Suwa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Kazuya Hattori
- Department of Diagnostic Pathology, Shizuoka Saiseikai General Hospital, Japan
| | - Hayato Ohtani
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Masao Saotome
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
| | - Satoshi Baba
- Department of Diagnostic Pathology, Hamamatsu University School of Medicine, Japan
| | | | - Yuichiro Maekawa
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Japan
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7
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Deharo F, Cosyns B, Arregle F, Habib G. Towards a new role for multimodality imaging in the diagnosis of cancer-associated marantic endocarditis. Arch Cardiovasc Dis 2023; 116:537-538. [PMID: 37863753 DOI: 10.1016/j.acvd.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/22/2023]
Affiliation(s)
- Francois Deharo
- Aix-Marseille University, Cardiology Department, service de cardiologie AP-HM, La Timone Hospital, boulevard Jean-Moulin, 13005 Marseille, France.
| | | | - Florent Arregle
- Aix-Marseille University, Cardiology Department, service de cardiologie AP-HM, La Timone Hospital, boulevard Jean-Moulin, 13005 Marseille, France
| | - Gilbert Habib
- Aix-Marseille University, Cardiology Department, service de cardiologie AP-HM, La Timone Hospital, boulevard Jean-Moulin, 13005 Marseille, France
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8
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Deharo F, Arregle F, Bohbot Y, Tribouilloy C, Cosyns B, Donal E, Di Lena C, Selton Suty C, Bourg C, Hubert S, Casalta JP, Philip M, Martel H, Gouriet F, Habib G. Multimodality imaging in marantic endocarditis associated with cancer: a multicentric cohort study. Eur Heart J Cardiovasc Imaging 2023; 24:1620-1626. [PMID: 37315206 DOI: 10.1093/ehjci/jead139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 05/12/2023] [Accepted: 06/03/2023] [Indexed: 06/16/2023] Open
Abstract
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.
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Affiliation(s)
- François Deharo
- Cardiology Department, Service de Cardiologie APHM, La Timone Hospital, Boulevard Jean Moulin, Marseille 13005, France
| | - Florent Arregle
- Cardiology Department, Service de Cardiologie APHM, La Timone Hospital, Boulevard Jean Moulin, Marseille 13005, France
| | - Yohann Bohbot
- Department of Cardiology, Amiens University Hospital, 80000, Amiens, France
| | | | | | - Erwan Donal
- Hospital Pontchaillou of Rennes, Rennes, France
| | - Chloe Di Lena
- Department of Cardiology, Amiens University Hospital, 80000, Amiens, France
| | | | | | - Sandrine Hubert
- Cardiology Department, Service de Cardiologie APHM, La Timone Hospital, Boulevard Jean Moulin, Marseille 13005, France
| | - Jean-Paul Casalta
- Cardiology Department, Service de Cardiologie APHM, La Timone Hospital, Boulevard Jean Moulin, Marseille 13005, France
| | - Mary Philip
- Cardiology Department, Service de Cardiologie APHM, La Timone Hospital, Boulevard Jean Moulin, Marseille 13005, France
| | - Helene Martel
- Cardiology Department, Service de Cardiologie APHM, La Timone Hospital, Boulevard Jean Moulin, Marseille 13005, France
| | - Frederique Gouriet
- Cardiology Department, Service de Cardiologie APHM, La Timone Hospital, Boulevard Jean Moulin, Marseille 13005, France
| | - Gilbert Habib
- Cardiology Department, Service de Cardiologie APHM, La Timone Hospital, Boulevard Jean Moulin, Marseille 13005, France
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9
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Celeng C, Takx RAP. Cancer-associated marantic endocarditis: a rare but relevant complication. Eur Heart J Cardiovasc Imaging 2023; 24:1627-1628. [PMID: 37421367 DOI: 10.1093/ehjci/jead162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/05/2023] [Indexed: 07/10/2023] Open
Affiliation(s)
- Csilla Celeng
- Department of Radiology and Nuclear Medicine, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584 CX, The Netherlands
| | - Richard A P Takx
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Location AMC, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
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10
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Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, Caselli S, Doenst T, Ederhy S, Erba PA, Foldager D, Fosbøl EL, Kovac J, Mestres CA, Miller OI, Miro JM, Pazdernik M, Pizzi MN, Quintana E, Rasmussen TB, Ristić AD, Rodés-Cabau J, Sionis A, Zühlke LJ, Borger MA. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023; 44:3948-4042. [PMID: 37622656 DOI: 10.1093/eurheartj/ehad193] [Citation(s) in RCA: 123] [Impact Index Per Article: 123.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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11
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Tonutti A, Scarfò I, La Canna G, Selmi C, De Santis M. Diagnostic Work-Up in Patients with Nonbacterial Thrombotic Endocarditis. J Clin Med 2023; 12:5819. [PMID: 37762758 PMCID: PMC10532023 DOI: 10.3390/jcm12185819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/23/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Nonbacterial thrombotic endocarditis (NBTE) is a form of endocarditis that occurs in patients with predisposing conditions, including malignancies, autoimmune diseases (particularly antiphospholipid antibody syndrome, which accounts for the majority of lupus-associated cases), and coagulation disturbances for which the correlation with classical determinants is unclear. The condition is commonly referred to as "marantic", "verrucous", or Libman-Sacks endocarditis, although these are not synonymous, representing clinical-pathological nuances. The clinical presentation of NBTE involves embolic events, while local valvular complications, generally regurgitation, are typically less frequent and milder compared to infective forms of endocarditis. In the past, the diagnosis of NBTE relied on post mortem examinations, while at present, the diagnosis is primarily based on echocardiography, with the priority of excluding infective endocarditis through comprehensive microbiological and serological tests. As in other forms of endocarditis, besides pathology, transesophageal echocardiography remains the diagnostic standard, while other imaging techniques hold promise as adjunctive tools for early diagnosis and differentiation from infective vegetations. These include cardiac MRI and 18FDG-PET/CT, which already represents a major diagnostic criterion of infective endocarditis in specific settings. We will herein provide a comprehensive review of the current knowledge on the clinics and therapeutics of NBTE, with a specific focus on the diagnostic tools.
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Affiliation(s)
- Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (A.T.); (C.S.)
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Iside Scarfò
- Applied Diagnostic Echocardiography Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (I.S.); (G.L.C.)
| | - Giovanni La Canna
- Applied Diagnostic Echocardiography Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (I.S.); (G.L.C.)
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (A.T.); (C.S.)
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Maria De Santis
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (A.T.); (C.S.)
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
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12
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Vattikonda KS, Peterson CJ, Ayzenbart VI, Rutherford MS. Nonbacterial Thrombotic Endocarditis With Embolic Phenomena Diagnosed by Transesophageal Echocardiogram. Cureus 2023; 15:e45686. [PMID: 37868389 PMCID: PMC10590079 DOI: 10.7759/cureus.45686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
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.
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Affiliation(s)
| | | | - Vira I Ayzenbart
- Cardiology, Virginia Tech Carilion School of Medicine, Roanoke, USA
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Bagheri A, Khani M, Akbari T, Ghadirzadeh E, Charkazi E, Ghorbani P. Trivalvular nonbacterial thrombotic endocarditis in a patient with colon adenocarcinoma: a case report. J Med Case Rep 2023; 17:334. [PMID: 37545010 PMCID: PMC10405455 DOI: 10.1186/s13256-023-04070-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
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.
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Affiliation(s)
- Abdolhamid Bagheri
- Department of Cardiology, Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, P.O. Box 1998734383, Tehran, Iran
| | - Mohammad Khani
- Department of Cardiology, Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, P.O. Box 1998734383, Tehran, Iran
| | - Tooba Akbari
- Department of Cardiology, Cardiovascular Research Center, Shahid Beheshti University of Medical Sciences, P.O. Box 1998734383, Tehran, Iran
| | - Erfan Ghadirzadeh
- Cardiovascular Research Center, Mazandaran University of Medical Sciences, Sari, Iran
| | | | - Parastoo Ghorbani
- Cardiovascular Research Center, Mazandaran University of Medical Sciences, Sari, Iran
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14
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Kurmann R, El-Am E, Ahmad A, Abbasi MA, Mazur P, Akiki E, Anand V, Herrmann J, Casanegra AI, Young P, Crestanello J, Bois MC, Maleszewski JJ, Klarich K. Cardiac Masses Discovered by Echocardiogram; What to Do Next? STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2023; 7:100154. [PMID: 37520139 PMCID: PMC10382990 DOI: 10.1016/j.shj.2022.100154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 12/06/2022] [Accepted: 12/21/2022] [Indexed: 02/12/2023]
Abstract
Cardiac tumors are rare conditions, typically diagnosed on autopsy, but with the advancement of imaging techniques they are now encountered more frequently in clinical practice. Echocardiography is often the initial method of investigation for cardiac masses and provides a quick and valuable springboard for their characterization. While some cardiac masses can be readily identified by echocardiography alone, several require incorporation of multiple data points to reach diagnostic certainty. Herein, we will provide an overview of the main clinical, diagnostic, and therapeutic characteristics of cardiac masses within the framework of their location.
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Affiliation(s)
- Reto Kurmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Edward El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ali Ahmad
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Piotr Mazur
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Elias Akiki
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Vidhu Anand
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Joerg Herrmann
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ana I. Casanegra
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Phillip Young
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Juan Crestanello
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Melanie C. Bois
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph J. Maleszewski
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kyle Klarich
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
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15
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Mayfield JJ, Otto CM. Stroke and Noninfective Native Valvular Disease. Curr Cardiol Rep 2023; 25:333-348. [PMID: 36971961 DOI: 10.1007/s11886-023-01855-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/09/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE OF REVIEW Embolic stroke of undetermined source is a challenging clinical entity. While less common than atrial fibrillation and endocarditis, many noninfective heart valve lesions have been associated with stroke and may be considered as culprits for cerebral infarcts when other more common causes are excluded. This review discusses the epidemiology, pathophysiology, and management of noninfective valvular diseases that are commonly associated with stroke. RECENT FINDINGS Calcific debris from degenerating aortic and mitral valves may embolize to the cerebral vasculature causing small- or large-vessel ischemia. Thrombus which may be adherent to calcified valvular structures or left-sided cardiac tumors may also embolize resulting in stroke. Tumors themselves, most commonly myxomas and papillary fibroelastomas, may fragment and travel to the cerebral vasculature. Despite this broad differential, many types of valve diseases are highly comorbid with atrial fibrillation and vascular atheromatous disease. Thus, a high index of suspicion for more common causes of stroke is needed, especially given that treatment for valvular lesions typically involves cardiac surgery whereas secondary prevention of stroke due to occult atrial fibrillation is readily accomplished with anticoagulation.
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Affiliation(s)
- Jacob J Mayfield
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, USA.
| | - Catherine M Otto
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, USA
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16
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Rahouma M, Khairallah S, Dabsha A, Elkharbotly IAMH, Baudo M, Ismail A, Korani OM, Hossny M, Dimagli A, Girardi LN, Mick SL, Gaudino M. Lung Cancer as a Leading Cause among Paraneoplastic Non-Bacterial Thrombotic Endocarditis: A Meta-Analysis of Individual Patients' Data. Cancers (Basel) 2023; 15:cancers15061848. [PMID: 36980734 PMCID: PMC10047261 DOI: 10.3390/cancers15061848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 03/04/2023] [Accepted: 03/13/2023] [Indexed: 03/30/2023] Open
Abstract
Hypercoagulability is strongly associated with cancer and may result in non-bacterial thrombotic endocarditis (NBTE). The aim of our meta-analysis was to explore the demographics and characteristics of this condition in cancer. Databases were systematically searched. The outcomes were to identify the annual trend in premortem diagnosis among the entire cohort and different subgroups and to identify differences in characteristics and survival in the considered population. A total of 121 studies with 144 patients were included. The proportion of marantic endocarditis associated with lung cancer was 0.29 (95% CI, 0.21-0.37; p < 0.001), that associated with pancreatic cancer was 0.19 (95% CI, 0.13-0.27; p < 0.001), that associated with advanced cancer stage (metastasis) was 0.69 (95% CI, 0.61-0.76; p < 0.001), and that associated with adenocarcinoma was 0.65 (95% CI, 0.56-0.72; p < 0.001). Median and 6-month overall survival (OS) were 1.3 months and 32.3%, respectively, with 6-month OS of 20.8% vs. 37.0% in lung vs. other cancers, respectively (p = 0.06) and 42.9% vs. 31.1% among those who underwent intervention vs. those who did not (p = 0.07). Cases discovered in recent years had better survival (HR = 0.98 (95% CI, 0.96-0.99; p = 0.003). While cancer-associated NBTE is a rare entity, lung cancers were the most common tumor site and are frequently associated with more advanced and metastatic cancer stages. The prognosis is dismal, especially among lung cancers.
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Affiliation(s)
- Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Sherif Khairallah
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Anas Dabsha
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Ismail A M H Elkharbotly
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
- General Surgery Department, Newham University Hospital, London E13 8SL, UK
| | - Massimo Baudo
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Department of Cardiac Surgery, Spedali Civili di Brescia, 25123 Brescia, Italy
| | - Amr Ismail
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Omnia M Korani
- Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo 12613, Egypt
| | - Mohamed Hossny
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
| | - Stephanie L Mick
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY 10021, USA
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17
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Otto CM. Heartbeat: knowledge gaps for non-bacterial thrombotic endocarditis. Heart 2022; 108:1583-1585. [PMID: 36162848 DOI: 10.1136/heartjnl-2022-321875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Catherine M Otto
- Division of Cardiology, University of Washington, Seattle, Washington, USA
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18
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Langston MC, Zack CJ, Fender EA. Non-bacterial thrombotic endocarditis: manifestations and diagnosis in the age of echocardiography. Heart 2022; 108:1590-1591. [PMID: 35609961 DOI: 10.1136/heartjnl-2022-321223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Matthew C Langston
- Cardiology, Christiana Care Health Services Inc, Wilmington, Delaware, USA
| | - Chad J Zack
- Cardiology, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Erin Amanda Fender
- Cardiology, Christiana Care Health Services Inc, Wilmington, Delaware, USA
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