Surgical pathology of nonbacterial thrombotic endocarditis in 30 patients, 1985-2000

From the archives of MD Anderson Cancer Center. Mesothelial/monocytic incidental cardiac excrescence with a review of the literature

Mesothelial/monocytic incidental cardiac excrescence (MICE) is a rare benign lesion composed of monocytes and mesothelial cells that is most often encountered during cardiothoracic surgery. We describe a case in a 71-year-old man with known aortic valve stenosis who presented with gradual onset dyspnea over a few weeks, made worse with minimal exertion. A transesophageal echocardiogram revealed severe aortic stenosis and mild pericardial effusion. The patient underwent aortic valve replacement, coronary artery bypass, and amputation of the left atrial appendage. Histological examination of a 0.8 cm blood clot received along with the atrial appendage showed an aggregation of bland cells with features of monocytes associated with small strands and nodules of mesothelial cells, fat cells, fibrin and a minute fragment of bone. Immunohistochemical analysis showed that the monocytic cells were positive for CD4 and CD68 (strong) and negative for calretinin and keratin. By contrast, the mesothelial cells were positive for calretinin and keratin and negative for all other markers. In sum, the morphologic and immunohistochemical findings support the diagnosis of MICE. Based on our review of the literature, about 60 cases of MICE have been reported previously which we have tabulated. We also discuss the differential diagnosis.

Usefulness of platelet count to predict concomitant valvular heart disease in patients with systemic lupus erythematosus

Background

Although the prevalence rate of valvular heart disease (VHD) is high in patients with systemic lupus erythematosus (SLE), the predictive factors of concomitant VHD have not been fully evaluated.

Methods and results

Among 288 patients with SLE who underwent transthoracic echocardiography at Kumamoto University Hospital from 2016 to 2021, 241 patients with sufficient echocardiographic data were retrospectively analysed. Among them, 22 (9 %) had VHD (10 had mitral regurgitation, 3 had aortic regurgitation, 6 had tricuspid regurgitation, 1 had mitral regurgitation and tricuspid regurgitation, and 2 had a prosthetic cardiac valve). After excluding the two patients with a prosthetic cardiac valve, we divided the remaining patients into two groups: the VHD group and non-VHD group. Multivariate logistic regression analysis revealed that age and the platelet count were significantly and independently associated with having VHD (age: odds ratio, 1.06; 95 % confidence interval, 1.02-1.10; p < 0.01) (platelet count: odds ratio, 0.99; 95 % confidence interval, 0.98-1.00; p < 0.05). After excluding 95 patients aged < 40 years, receiver operating characteristic analysis revealed that the area under the curve of the platelet count for prediction of VHD was 0.73 with an optimal cut-off value of 166.5 × 103/µL (sensitivity: 76.6 %, specificity: 60.0 %). Among patients with a low platelet count (<166.5 × 103/µL), the rate of having VHD was 29 % (12/41 patients). However, among those with a high platelet count (≥166.5 × 103/µL), this rate was only 8 % (8/103 patients).

Conclusion

The platelet count is useful to predict concomitant VHD in middle-aged and older patients with SLE.

Postoperative anticoagulation management using subcutaneous unfractionated heparin for a patient with nonbacterial thrombotic endocarditis: a case report

Nonbacterial thrombotic endocarditis (NBTE) presents nonbacterial vegetation on cardiac valves. NBTE requires appropriate anticoagulant therapy to prevent recurrence after surgery. However, there has not yet been established evidence for anticoagulant therapy in NBTE, and low molecular weight heparin is not approved in Japan. We present a case of NBTE that was successfully managed with anticoagulant therapy using subcutaneous unfractionated heparin. A 59-year-old woman was diagnosed with NBTE on the mitral and tricuspid valve associated with breast cancer, underwent valve replacement. Warfarin and continuous intravenous unfractionated heparin were started. However, disseminated intravascular coagulation occurred after heparin was discontinued. Continuous intravenous unfractionated heparin injection was resumed immediately, and subcutaneous unfractionated heparin was administered before discharge. Postoperative echocardiography revealed no vegetation on the prosthetic valves thereafter. Subcutaneous unfractionated heparin therapy is useful to prevent the recurrence of NBTE as the anticoagulation in outpatients.

Systemic embolization due to non-bacterial thrombotic endocarditis: An autopsy case report and mini review of the literature

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.

Diagnostic Challenges of Systemic Lupus Erythematosus

Systemic lupus erythematosus (SLE) is a disease characterized by clinical heterogeneity with unpredictable course. Several disease endotypes have been identified, including SLE with antiphospholipid syndrome (APS). We report a case of a pregnant woman with hypertension and proteinuria, diagnosed with APS, Libman-Sacks endocarditis that led to moderate to severe mitral valve insufficiency, and SLE. We describe the diagnostic steps, evolution, and complications. This case highlights the asynchrony behavior of SLE, emphasizing the importance of a multidisciplinary approach to an early diagnosis.

An Incidental Finding of Libman-Sacks Endocarditis ‎in a Young Female With Systemic Lupus Erythematosus Who Presented With Pleuritic Chest Pain

Libman-Sacks endocarditis (LSE) is a rare disease found incidentally in ‎postmortem autopsies, characterized by microscopic to large ‎verrucous vegetation on the cardiac valves, the most affected site is ‎the mitral valve followed by the aortic valve. Females of reproductive age ‎were observed as the most affected individuals as found in studies. ‎Most individuals with LSE are asymptomatic and ‎generally discovered lately when they presented with ‎thromboembolic disorders such as stroke, cognitive disabilities, and death. ‎Malignancy and autoimmune diseases involving systemic lupus ‎erythematosus (SLE) and antiphospholipid syndrome (APS) are ‎considered the primary etiology of LSE. As recognized, the majority of LSE cases are ‎asymptomatic, it tends to be challenging to spot the condition ‎at the early pathway of the disease. In this paper, we describe a ‎young female who is known to have SLE on medications, she presented ‎to the emergency department (ED) due to chest pain and exertional ‎dyspnea for a few days, laboratory investigations showed ‎anemia, raised inflammatory marker, and anti-DsDNA. Imaging ‎studies showed bilateral pleural effusion on the chest X-ray ‎and a large vegetation on the posterior mitral valve with moderate regurgitation and normal wall ‎motion in transesophageal echocardiography. The patient was managed by pulse steroid therapy, anticoagulation ‎therapy, and a low dose of diuretic, the patient improved dramatically and ‎discharged home with close follow-up in the clinic. The primary ‎treatment of LSE is anticoagulant therapy, however, surgical ‎intervention should be considered in case of large vegetation ‎recurrent thromboembolism despite anticoagulant therapy. As ‎the prognosis in LSE is considered very poor and there is no definitive laboratory investigation ‎exists to confirm the diagnosis, we highlight the importance of ‎considering LSE as a serious and crucial differential diagnosis ‎when dealing with SLE patients who presented with dyspnea and pleural effusion secondary to valvular dysfunction, mainly the mitral valve.

Non-bacterial thrombotic endocarditis in a patient with COVID

Non-bacterial thrombotic endocarditis is mainly associated with malignancies and rheumatological diseases. We report the case of mildly symptomatic COVID-19 infection with non-bacterial aortic valve vegetation complicated by transient ischemic attack (TIA) and pulmonary embolism during his hospitalisation. This case emphasised rare life-threatening complications from a hypercoagulable state related to COVID-19 infection. To the best of our knowledge, this is the third case report of non-bacterial endocarditis in a patient with COVID-19 patients as a potential rare complication of COVID-19.

Multi-valve Libman-Sacks's endocarditis-related multiple, massive and fatal systemic embolization. A case report and a review of diagnostic work-up

We reported a case of non-bacterial thrombotic endocarditis (NBTE) in a 37-year-old woman who presented with signs and symptoms of cardio-embolic cerebral stroke caused by a prothrombotic state due to underlying advanced uterine cancer. Multimodal imaging, including 3D-ecocardiography, as well as laboratory and cultural tests, were critical in making the diagnosis. After starting anticoagulation therapy with low molecular weight heparin (LMWH), the patient underwent surgical aortic valve replacement due to worsening aortic valve function, initial left ventricle enlargement, increasing dimensions, and mobility of vegetations. Unfortunately, vegetations relapsed on the aortic valve bio-prosthesis as well as the mitral leaflets, resulting in a final picture of multi-valve NBTE. The fatal outcome was due to a massive multiple limb embolism, which resulted in leg amputations and septical complications. Starting with the case, we present a brief overview of the pathology's presentation, treatment, management, and prognosis, as well as the diagnostic work-up.

Diagnostic Work-Up in Patients with Nonbacterial Thrombotic Endocarditis

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.

Cardiac Masses Discovered by Echocardiogram; What to Do Next?

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.

Inflammatory and thrombotic valvulopathies in autoimmune disease

Rheumatologic diseases are characterised by loss of immune tolerance, resulting in systemic inflammation. Inflammation and scarring of the endocardium, which lines the inner surface of the heart chambers and valves, can result in valvular thickening and dysfunction. Estimates of prevalence vary depending on the sensitivity of the screening methodology used and range from 30%-50% in systemic lupus and rheumatoid arthritis to 10%-30% in ankylosing spondylitis. Progression of valve disease is a slow process but can result in haemodynamically significant complications. Thromboembolic complications such as cerebrovascular occlusions pose a serious risk of morbidity. The presence of antiphospholipid antibodies increases the risk of valvular disease and thrombotic complications. Anticoagulation is recommended in the presence of antiphospholipid antibodies, but the guidance on the role of immunosuppressive therapy to treat valvular disease is lacking. Surgical valve therapy may be considered in severe disease, but there is increased risk in patients with an autoimmune disease which includes a higher risk of infection, thromboembolic and bleeding complications, as well as cardiovascular events in the setting of premature atherosclerotic heart disease. Therefore, management should be provided in a multidisciplinary team that includes a rheumatologist, a cardiologist and a cardiothoracic surgeon; medical therapy should be optimised before considering a high-risk valve surgery.

Lung Cancer as a Leading Cause among Paraneoplastic Non-Bacterial Thrombotic Endocarditis: A Meta-Analysis of Individual Patients' Data

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.

Severe Libman-Sacks endocarditis complicating antiphospholipid syndrome: a retrospective analysis of 23 operated cases

OBJECTIVE

Data on severe heart valve disease (HVD), including Libman-Sacks endocarditis, associated with SLE and/or APS requiring valvular surgery are scarce. We thus conducted a retrospective study, aimed at describing and clarifying clinical, laboratory, echocardiographic, histopathological and evolutional features of SLE and/or APS patients with severe associated-HVD.

METHODS

An observational retrospective multicentric analysis of 23 adults with SLE and/or APS and HVD between 1996 and 2019 and available histopathological report evaluating long-term follow-up.

RESULTS

Twenty-three individuals (20 females, median age 37 [range 17-76] years) were included. All had APS (thrombotic in 22, with an arterial phenotype in 15 and with catastrophic APS [CAPS] in six), and 11 (47%) had SLE. Systemic underlying disease had been diagnosed prior to HVD in 12 (52%). In 10 patients (43%), HVD was complicated by cerebral stroke prior to surgery. Twenty patients (87%) had only one pathological valve, the mitral valve in 18 patients (78%). Valvular thickening (n = 19) and valvular regurgitation (n = 19) were the most frequently reported lesions. Fifteen (62%) patients underwent mechanical valve replacement, six (26%) conservative valve repair (five were later re-operated after a median time of 1 [0-4] year), and two (9%) underwent biological valve replacement. Nine patients (39%) presented early-onset post-operative complications, including three CAPS immediately after surgery and one death. After surgery, 18 patients (78%) had normal postoperative valvular function, but almost half of the patients (43%) had post-operative neurological sequelae (median follow-up of 6 [2-20] years).

CONCLUSION

Severe HVD leading to surgery was strongly associated with thrombotic APS, especially arterial phenotypes. Half of the reported patients presented cerebral stroke complicating the HVD. Valvular surgery carried a significant risk of CAPS.

Malignancy and Endocarditis: Divulging Into the Intertwined Association

Cancer is an immunosuppressive disorder with characteristic features of unchecked cell growth, invasion, and sometimes thromboembolism leading to multiple systemic sequelae, including infective endocarditis. This article has compiled some of the crucial mechanisms by which infective endocarditis occurs in cancer patients, its risk factors, and the existing treatment interventions. It has focused on the necessity of being aware that these multiple pathogeneses are involved in the development of infective endocarditis (IE) in cancer patients, which would help delineate the risk factors associated with the condition and help physicians screen better for specific red flags. Identifying these risk factors and patient-oriented therapy, targeting the necessary elements such as causative organism, patient immune status, type of cancer, choosing evidence-based treatment modalities, and to improve the outcome of the disease in an already exasperating condition called cancer.

EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography

Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.

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.

Cancer-Related Non-Bacterial Thrombotic Endocarditis Presenting as Acute Ischemic Stroke

Non-bacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis, is a rare form of noninfectious endocarditis presenting with thromboembolism including ischemic cerebral stroke. It is mostly associated with advanced malignancy and characterized by the presence of sterile vegetation on heart valves. The diagnosis is usually based on vegetations seen on an echocardiogram, with negative blood cultures suggesting a noninfectious etiology. The treatment for this condition includes systemic anticoagulation. In this report, we discuss the case of a 61-year-old Caucasian female who presented to our facility with an ischemic stroke. She was found to have vegetations on the mitral valve with negative blood cultures. Further studies revealed metastatic pancreatic cancer. The patient's condition improved following in-hospital management, and she was discharged home for outpatient follow-up and treatment. Through this report, we highlight the importance of considering a search for malignancy in patients presenting with these clinical features. Early diagnosis and prompt management are critical to reduce the complications of NBTE and improve the patients' quality of life.

Antithrombotic Therapy for Stroke Patients with Cardiovascular Disease

Prevention of ischemic stroke relies on the use of antithrombotic medications comprising antiplatelet agents and anticoagulation. Stroke risk is particularly high in patients with cardiovascular disease. This review will focus on the role of antithrombotic therapies in the context of different types of cardiovascular disease. We will discuss oral antiplatelet medications and both IV and parental anticoagulants. Different kinds of cardiovascular disease contribute to stroke via distinct pathophysiological mechanisms, and the optimal treatment for each varies accordingly. We will explore the mechanism of stroke and evidence for antithrombotic therapy in the following conditions: atrial fibrillation, prosthetic heart values (mechanical and bioprosthetic), aortic arch atherosclerosis, congestive heart failure (CHF), endocarditis (infective and nonbacterial thrombotic endocarditis), patent foramen ovale (PFO), left ventricular assist devices (LVAD), and extracorporeal membrane oxygenation (ECMO). While robust data exist for antithrombotic use in conditions such as atrial fibrillation, optimal treatment in many situations remains under active investigation.

Nonbacterial thrombotic endocarditis in a patient with gastric cancer and SARS-CoV-2 infection

Nonbacterial thrombotic endocarditis, formerly known as marantic endocarditis, is a very rare complication of advanced malignancy and other hypercoagulable states in which sterile, fibrin vegetations develop on heart valve leaflets. The most common malignancies associated with this entity are lung, pancreatic and gastric cancer. It has also been described as a presentation of COVID-19, which is known to be frequently complicated with coagulopathy and thromboembolic events. We report the case of a 62 year-old female patient newly diagnosed with stage IV gastric cancer and acute SARS-CoV-2 infection, presenting with confusion and homonymous hemianopsia in the setting of multiple acute ischemic strokes complicating a nonbacterial thrombotic mitral endocarditis. Herein, we discuss the underlying pathophysiology and make the hypothesis that SARS-CoV-2 infection could have participated in the pathogenesis of nonbacterial thrombotic endocarditis in our patient suffering from a gastric cancer.

Non-bacterial thrombotic endocarditis manifested by ventricular fibrillation in a patient with low grade ovarian carcinoma: case report and literature review

Background

Non-bacterial thrombotic endocarditis (NBTE) is a rare form of endocarditis notably described in patients with advanced malignancy and auto-immune diseases. It is characterized by the formation of sterile, fibrin-containing vegetations on cardiac endothelium, in the absence of positive blood cultures. It is predominantly located on the mitral- and aortic valve (AV). Vegetations in NBTE are prone to embolize. Trousseau syndrome (TS) is defined as unexplained thrombotic events that precede the diagnosis of malignancy.

Case summary

A 49-year-old pre-menopausal woman with a history of visual disturbances, recurrent deep vein thrombosis (DVT) with concurrent pulmonary emboli (PE), and uterine myomas with dysfunctional uterine bleeding was resuscitated for ventricular fibrillation. While echocardiography revealed vegetations on the AV, blood cultures remained negative. Additional work-up for the aetiology of sterile vegetations revealed a low-grade ovarian carcinoma. Cardiac analysis showed evidence of myocardial infarction in the absence of coronary atherosclerosis as a cause for ventricular fibrillation.

Discussion

Unexplained thrombotic events (venous, arterial, or both) warrant further investigation, e.g., with regard to TS. NBTE is a potential source of thromboembolism in TS and a rare ante-mortem finding, which prompts additional investigation of the underlying cause. In our patient, a triad of (suspected) (i) arterial/systemic embolization (i.e. visual disturbances, splenic infarction, coronary embolism), (ii) peripheral thrombophlebitis/hypercoagulability (i.e. DVT and PE), and (iii) malignancy (i.e. gynaecological abnormalities) raised suspicion of NBTE in the setting of TS. Early diagnosis and treatment of NBTE is of importance due to the high incidence of embolization, with possible fatal outcome.

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.

Neurologic complications of nonbacterial thrombotic endocarditis

Endocarditis is an inflammatory or infective condition affecting the cardiac valves or endocardium, often associated with serious neurological sequelae. Nonbacterial thrombotic endocarditis (NBTE)-referred to as degenerative, Libman-Sachs, marantic, verrucous, or terminal endocarditis-is a serious but rare cause of valvular heart disease characterized by deposition of sterile vegetations of fibrin and platelet aggregates on the cardiac valves, eventually resulting in life-threatening embolization of these thrombi to the brain, limbs, or visceral organs. NBTE may complicate a heterogeneous group of chronic conditions, predominantly connective tissue and autoimmune disorders, malignancies, and diseases associated with hypercoagulability states. NBTE usually affects the native rather than prosthetic valves, and unlike infective endocarditis (IE), sparing the involved valve function without its destruction. Compared to those seen in IE, vegetations in NBTE are small and friable, thus may easily be dislodged leading to systemic thromboembolism with devastating morbidities and mortality. There are no diagnostic criteria for NBTE, and antemortem diagnosis is challenging. The condition should be suspected in patients with thromboembolic events and vegetations on the cardiac valves on echocardiographic or cardiac imaging studies, in the absence of underlying infection, especially in disorders predisposing to coagulopathy. Early recognition and prompt treatment of the primary underlying disorder is essential. Anticoagulation with heparin or heparinoid products is recommended to prevent recurrent embolism. Surgical intervention is not indicated except in selected patients with life-threatening recurrent embolism.

Nonbacterial Thrombotic Endocarditis-A Rare Case of Acute Libman-Sacks Endocarditis Complicated by Multiple Cerebral Infarcts: Case Report and Literature Review

•

Acute NBTE can be diagnosed on TTE and TEE.

•

LSE complicated by multiple coagulopathies may trigger NBTE and cerebral infarcts.

•

Screening with TTE is essential in patients with SLE with multiple risk factors.

Mitral Valve Prosthesis Dehiscence with Severe Regurgitation and Pseudoaneurysm in a Young Woman with Recurrent Nonbacterial Thrombotic Endocarditis

•

NBTE can present with extensive tissue destruction warranting complex surgeries.

•

Echocardiography is crucial in guiding the surgical plan and detecting complications.

•

The cardiac skeleton can be surgically reconstructed, but complications are high.

Chemotherapy-associated nonbacterial thrombotic endocarditis: A radiological mimicker of cardiac amyloidosis requiring histopathologic examination for definitive diagnosis

Nonbacterial thrombotic endocarditis is a form of a thrombotic angiopathy involving the endothelial lined endocardial surfaces of the heart which includes valves and the chamber walls. Underlying etiologies for nonbacterial thrombotic endocarditis include autoimmune diseases, hypercoagulable states, in the setting of certain malignant neoplasms, and physical injury. The pathogenesis for these processes is that of primary endothelial injury resulting in a thrombotic angiopathy. We present a patient with heart failure being evaluated before hematopoietic stem cell transplantation who had previously been provided with chemotherapy and whose cardiac magnetic resonance imaging reveals findings suggestive of amyloidosis. A subsequent endomyocardial biopsy instead showed nonbacterial thrombotic endocarditis characterized by the endocardium with fibromyxoid thickening and overlying fresh fibrin. This case highlights histopathologic findings of chemotherapy-associated nonbacterial thrombotic endocarditis involving the right ventricle wall of the endocardium, therefore expanding the radiological differential in patients with cardiac magnetic resonance imaging findings suggestive of amyloidosis.

Atypical marantic endocarditis

Marantic endocarditis is a rare non-infectious endocarditis that mostly affects the aortic and mitral valves. It is often an autopsy finding that is most commonly seen in advanced malignancies thought to be due to a hypercoagulable state. When diagnosed antemortem, it typically presents with signs and symptoms of embolisation. We report a case of a 44-year-old Caucasian man with marantic endocarditis secondary to metastatic small cell lung cancer. Our patient presented with a short history of lower back pain with no signs/symptoms of embolisation, and a pansystolic murmur on initial physical examination. Serial blood cultures were negative and transthoracic echocardiography revealed vegetation on the posterior leaflet of the mitral valve. Further imaging in the form of MRI spine and CT thorax/abdomen/pelvis showed pulmonary lesions with liver and bony metastasis. Subsequent image-guided biopsy confirmed metastatic small cell lung cancer of T1N2M1c grade, which was treated with palliative chemotherapy and radiotherapy.

Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Patients With Rheumatoid Arthritis (from the Nationwide Inpatient Database)

Little is known on the outcomes of surgical aortic valve replacement (SAVR) versus transcatheter aortic valve implantation (TAVI) in patients with rheumatoid arthritis (RA). We queried the Nationwide Inpatient Sample Database (2012 to 2016). We performed a propensity-score-matched analysis based on 25 clinical and hospital variables to compare patients with RA who underwent SAVR versus TAVI. Our primary outcome was in-hospital mortality. Our final analysis included 5,640 hospitalizations with RA who underwent isolated AVR; of whom, 2,465 (43.7%) underwent TAVI. There was an increasing trend in TAVI procedures during the study years (p_trend= 0.001). There was a trend toward reduced in-hospital mortality among TAVI compared with SAVR but did not reach statistical significance (0.8% vs 1.6%, odds ratio = 0.50; 95% confidence interval 0.23 to 1.06, p = 0.097). TAVI was associated with lower rates of postoperative bleeding (28.7% vs 43.9%, p <0.001), blood transfusion (12.3% vs 40.2%, p <0.001), acute kidney injury (9.8% vs 16.0%, p <0.001), cardiac tamponade (0.0% vs 1.6%, p <0.001), and discharges to skilled nursing facility (SNF) (20.1% vs 42.2%, p <0.001). However, TAVI was associated with a higher rate of complete heart block (14.3% vs 6.1%, p <0.001) and pacemaker implantations (14.8% vs 5.7%, p <0.001). There were no differences between both groups in cardiogenic shock, acute stroke, acute myocardial infarction, and vascular complications. In conclusion, real-word data showed no significant difference in in-hospital mortality between TAVI and SAVR in patients with RA. TAVI was associated with lower rates of acute kidney injury and bleeding complications at the expense of higher incidence of pacemaker implantations.

Nonbacterial thrombotic endocarditis

An 83-year-old woman with a 10-year history of rheumatoid arthritis was admitted for urinary tract infection with exacerbation of chronic kidney disease and decompensated heart failure of unknown etiology. Transesophageal echocardiography (TEE) showed a vegetation involving the posterior mitral valve leaflet, and a hypothesis of infective endocarditis was proposed. Empirical antibiotic therapy was initiated. TEE was repeated after antibiotic therapy, and showed persistence of the original vegetation and revealed the presence of another, smaller vegetation. Clinical investigation revealed no infectious process, and so a diagnosis of nonbacterial thrombotic endocarditis (NBTE) was established. Anticoagulant therapy was started immediately. The NBTE lesion had disappeared on the follow-up echocardiogram two months after anticoagulant therapy.

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.

Anticoagulation in the cardiac patient: A concise review

Anticoagulation has multiple roles in the treatment of cardiovascular disease, including in management of acute myocardial infarction, during percutaneous coronary intervention, as stroke prophylaxis in patients with atrial arrhythmias, and in patients with mechanical heart valves. Clinical anticoagulation choices in the aforementioned diseases vary widely, due to conflicting data to support established agents and the rapid evolution of evidence-based practice that parallels more widespread use of novel oral anticoagulants. This review concisely summarizes evidence-based guidelines for anticoagulant use in cardiovascular disease, and highlights new data specific to direct oral anticoagulants.

Primary Nonbacterial Thrombotic Endocarditis Presenting with Bowel Infarction Secondary to Superior Mesenteric Artery Embolism

Nonbacterial thrombotic endocarditis (NBTE) is a rare antemortem diagnosis that is commonly associated with hypercoagulable states such as advanced malignancies, disseminated intravascular coagulation, and autoimmune diseases such as antiphospholipid syndrome and systemic lupus erythematosus. We present a case of a previously healthy 42-year-old man who presented with small bowel infarction caused by embolic occlusion of the superior mesenteric artery and was subsequently diagnosed with NBTE. Despite thorough investigation, efforts to find an underlying cause failed to reveal any associated systemic illnesses. This case report emphasizes the importance of further investigation into the possible underlying causes of NBTE, as it can manifest without any apparent systemic factors.

Infectious endocarditis: An update for emergency clinicians

INTRODUCTION

Infectious endocarditis (IE) is a potentially deadly disease without therapy and can cause a wide number of findings and symptoms, often resembling a flu-like illness, which makes diagnosis difficult.

OBJECTIVE

This narrative review evaluates the presentation, evaluation, and management of infective endocarditis in the emergency department, based on the most current literature.

DISCUSSION

IE is due to infection of the endocardial surface, most commonly cardiac valves. Major risk factors include prior endocarditis (the most common risk factor), structural heart damage, IV drug use (IVDU), poor immune function (vasculitis, HIV, diabetes, malignancy), nosocomial (surgical hardware placement, poor surgical technique, hematoma development), and poor oral hygiene, and a wide variety of organisms can cause IE. Patients typically present with flu-like illness. Though fever and murmur occur in the majority of cases, they may not be present at the time of initial presentation. Other findings such as Roth spots, Janeway lesions, Osler nodes, etc. are not common. An important component is consideration of risk factors. A patient with IVDU (past or current use) and fever should trigger consideration of IE. Other keys are multiple sites of infection, poor dentition, and abnormal culture results with atypical organisms. If endocarditis is likely based on history and examination, admission for further evaluation is recommended. Blood cultures and echocardiogram are key diagnostic tests.

CONCLUSIONS

Emergency physicians should consider IE in the patient with flu-like symptoms and risk factors. Appropriate evaluation and management can significantly reduce disease morbidity and mortality.

Nonbacterial thrombotic endocarditis in a patient with primary antiphospholipid syndrome

Nonbacterial thrombotic endocarditis (NBTE) is described in patients with mucin-producing cancers and connective tissue disorders (usually SLE). We report NBTE in the setting of primary antiphospholipid antibody syndrome (APS). A 65-year-old female with APS was incidentally found to have thickened mitral leaflets on transthoracic echocardiogram with no signs of infection. Transesophageal echocardiogram (TEE) showed a mobile mitral mass (1.4 × 0.7 cm) and moderate mitral regurgitation. Differential diagnoses included bacterial endocarditis, NBTE, thrombus or tumor. Given the history of primary APS, the absence of fever and negative blood cultures, NBTE was considered. Low-molecular-weight heparin, hydroxychloroquine and corticosteroid were initiated. Repeat TEE in a week revealed shrinkage of the mass (0.6 × 0.7 cm), indicating an inflammatory nature. Lifelong anticoagulation is indicated regardless of embolism occurrence. Hydroxychloroquine and corticosteroids may have roles in the treatment. Determining and treating the underlying etiology is important.

Procedural and clinical outcomes of endovascular recanalization therapy in patients with cancer-related stroke

Objective Embolism due to coagulopathy might be the main pathomechanism underlying cancer-related stroke (CRS). CRS patients with a large artery occlusion could be candidates for endovascular recanalization therapy (ERT), although its procedural and clinical outcomes are not well known. This study aimed to investigate the procedural and clinical outcomes of ERT in CRS patients and the characteristics associated with outcomes compared with those of conventional stroke patients. Methods A registry of consecutive acute ischemic stroke patients who underwent ERT between January 2011 and October 2015 was retrospectively reviewed. CRS patients are described as those who had (a) cryptogenic stroke with advanced or metastatic cancer; (b) no other possible causes of stroke such as cardioembolism (CE) and large artery atherosclerosis (LAA); and (c) elevated D-dimer levels or diffusion-restricted lesions in multiple vascular territories. We compared procedural and clinical outcomes at discharge among CRS, CE, and LAA patients. Results A total of 329 patients were finally enrolled in this study; of these, 19 were CRS patients. The rate of successful recanalization, defined as modified treatment in cerebral infarction grade 2b or 3, was lower in the CRS group than in the LAA and CE groups (63% versus 84% versus 84%, p = .06). CRS subtype was an independent predictor for successful recanalization after ERT in the multivariate analysis (odds ratio, 0.317; 95% confidence interval, 0.116-0.867; p < .001). No significant difference in the rate of good clinical outcomes at discharge was observed among groups. Conclusions Although clinical outcomes at discharge were similar for CE and LAA patients, complete recanalization seemed more difficult to achieve in CRS patients than in conventional stroke patients.

Recurrent nonbacterial thrombotic endocarditis: A novel therapeutic approach

We present the case of a 29-year-old male with a history of Mizuho hemolytic anemia, a rare form of unstable hemoglobinopathy, who presented with congestive heart failure secondary to recurrent valve thrombosis despite appropriate oral anticoagulation. He subsequently required mitral and aortic valve replacement. Pathologic examination revealed extensive nonbacterial thrombotic endocarditis. Due to recurrent thrombosis despite therapeutic anticoagulation, we elected to treat him with red blood cell exchange transfusions and hydroxyurea. He has remained free of symptoms for almost two years with this treatment regimen without side effects. <Learning objective: The management of nonbacterial thrombotic endocarditis (NBTE) is well described in the literature. However, the treatment for refractory NBTE in aggressive forms of unstable hemoglobinopathy remains difficult. The use of hydroxyurea and serial red blood cell exchange, in addition to the usual therapies, may be useful in the treatment of refractory NBTE.>.

Antiphospholipid Antibodies and Heart Valve Disease in Systemic Lupus Erythematosus

Evaluation of antiphospholipid antibodies (aPL) and correlation with heart valve abnormalities among patients with systemic lupus erythematosus (SLE). Nested case-control study was conducted with 70 patients with SLE selected from a longitudinal database based on levels of aPL and presence or absence of valve disease by echocardiogram. Valvular abnormalities observed were regurgitation (52), other (14), artificial valves (4), stenosis (2), thickening (2) and no Libman-Sacks endocarditis (0). The mitral valve was the most commonly affected (30 abnormalities), followed by the tricuspid (20 abnormalities). Multivariate logistic regression for those with and without an aPL value ≥20 units/mL, adjusted for disease duration and age, showed significant differences for any valve abnormality (odds ratio [OR] = 3.1; 95% CI: 1.0-8.9; P = 0.041) and individually for the tricuspid valve (OR = 3.3; 95% CI: 1.0-11.1; P = 0.052) but not for the mitral valve (OR = 2.1; 95% CI: 0.68-6.45; P = 0.195). Levels of aPL ≥20 units/mL showed no association with aortic (P = 0.253), pulmonic (P = 1.000), tricuspid (P = 0.127), or mitral (P = 0.249) valve abnormalities. Levels of aPL correlate with certain valvular abnormalities among patients with SLE.

A classical case of non-bacterial thrombotic endocarditis from pancreatic adenocarcinoma presenting as multiple strokes, myocardial infarction and acute limb ischaemia

Non-bacterial thrombotic endocarditis (NBTE) classically presents in the context of pancreatic adenocarcinomas. Echocardiography is useful to investigate for valvular vegetations, and institution of early treatment is crucial as this can be complicated by multiple systemic emboli, leading to significant morbidity or mortality in serious cases. Treatment options involve anticoagulation with unfractionated heparin, and the role of surgical intervention is unclear. In this report, we describe a classical case of a middle-aged lady with unresectable pancreatic adenocarcinoma who developed NBTE complicated by multiple systemic emboli. She eventually succumbed from poor neurological status from multiple cerebral emboli. Awareness of this condition is required by clinicians for early diagnosis and prompt treatment.

Cardiac involvement in systemic lupus erythematosus

Pericarditis is the most common cardiac abnormality in systemic lupus erythematosus (SLE) patients, but lesions of the valves, myocardium and coronary vessels may all occur. In the past, cardiac manifestations were severe and life threatening, often leading to death. Therefore, they were frequently found in post-mortem examinations. Nowadays cardiac manifestations are often mild and asymptomatic. However, they can be frequently recognized by echocardiography and other noninvasive tests. Echocardiography is a sensitive and specific technique in detecting cardiac abnormalities, particularly mild pericarditis, valvular lesions and myocardial dysfunction. Therefore, echocardiography should be performed periodically in SLE patients. Vascular occlusion, including coronary arteries, may develop due to vasculitis, premature atherosclerosis or antiphospholipid antibodies associated with SLE. Premature atherosclerosis is the most frequent cause of coronary artery disease (CAD) in SLE patients. Efforts should be made to control traditional risk factors as well as all other factors which could contribute to atherosclerotic plaque development.