Endocarditis trombótica no bacteriana y adenocarcinoma de endometrio / Non-bacterial thrombotic endocarditis and endometrious adenocarcinoma

Se describe el caso de una mujer de 80 años, con antecedentes de trombosis venosa profunda en tratamiento con apixaban, que presenta clínica focal neurológica. Las pruebas de imagen evidencian múltiples émbolos arteriales en cerebro, riñones y bazo, así como imagen sugestiva de neoplasia uterina. Una biopsia tras histeroscopia, confirma el diagnóstico de adenocarcinoma de endometrio. La ecocardiografía transesofágica constata la existencia de vegetaciones en válvulas cardíacas, siendo los estudios infecciosos negativos. Es diagnosticada de endocarditis trombótica no bacteriana relaciona con una neoplasia. Se cambia apixaban por heparina de bajo peso molecular, confirmando la práctica desaparición delas vegetaciones. (AU)

We present a case of an 80-year-old woman with a history of deep vein thrombosis, treated with apixaban, which has a focal neurological clinic. Imaging tests show multiple arterial ischemic lesions in brain, kidneys and spleen, as well as suggestive imaging of uterine neoplasia. A biopsy after hysteroscopy confirms the diagnosis of endometrial adenocarcinoma. Transesophageal echocardiography shows vegetations in valves, with negative blood cultures. The diagnostic was non-bacterial thrombotic endocarditis related to cancer. The anticoagulant was changed to low molecular weight heparin, confirming the disappearance of vegetations. (AU)

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

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

[Non-infective endocarditis]. / Les endocardites non infectieuses.

Non-infective endocarditis, also referred to as non-bacterial thrombotic endocarditis, represent a wide range of rare pathologies, often severe. This review gathered the data available in the literature, to decipher the major information collected on the pathophysiology, the diagnosis and the treatment of these heterogeneous diseases, often misdiagnosed. Characteristics of non-infective endocarditis are similar to infective endocarditis in terms of valvular lesions (mostly left-sided, with regurgitations and vegetations), and their complications (embolism). The diagnosis of non-infective endocarditis is usually considered in patients with blood culture-negative endocarditis. Beyond the usual suspects - marastic endocarditis and systemic lupus erythematosus - which represent more than 75% of the cases, Behçet disease and hypereosinophilic syndrome are the main causes of non-infective endocarditis. More seldomly, rheumatoid arthritis, adult-onset Still disease, allergy to pork in patients with valvular procine bioprosthesis, systemic scleroderma, Cogan or Sneddon syndrome should be suspected. Diagnostic approach is based on history and physical examination, with a special focus on extra-cardiac manifestations, as well as echocardiography, and computed tomography. Treatment relies on intensive management of the underlying disease. Curative anticoagulation is often necessary. Although indications for cardiac surgery are poorly defined, as compared to infective endocarditis, data currently available suggest that an optimal control of the underlying disease before cardiac surgery is of utmost importance, as it dramatically reduces the risk of postoperative complications.

Nonbacterial Thrombotic Endocarditis: Pathogenesis, Diagnosis, and Management.

Nonbacterial thrombotic endocarditis (NBTE), formerly known as marantic endocarditis, is a potentially overlooked condition that involves the formation of sterile, fibrin vegetations on heart valve leaflets. Often confused with classic infective endocarditis during its early stages, NBTE can lead to valvular dysfunction, heart failure, and systemic embolization when unchecked. The pathogenesis is not entirely clear but involves a preexisting hypercoagulable state. Diagnosis requires ruling out infection and establishing the presence of valvular vegetations using echocardiography. Therapy for NBTE includes treating the underlying disease, systemic anticoagulation and surgical intervention.

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

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

Prosthetic valve endocarditis after transcatheter aortic valve implantation.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is an advancing mode of treatment for inoperable or high-risk patients with aortic stenosis. Prosthetic valve endocarditis (PVE) after TAVI is a serious complication, but only limited data exist on its incidence, outcome, and procedural risk factors. METHODS AND RESULTS: Observational single-center study of 509 consecutive patients treated with a transcatheter implanted self-expandable aortic valve prosthesis (Medtronic CoreValve). We identified 18 patients diagnosed with TAVI-PVE during a median follow-up period of 1.4 years (interquartile range, 0.5-2.5 years; longest follow-up was 6.3 years). TAVI-PVE was most frequent in the first year after implantation (first-year incidence, 3.1% [confidence interval, 1.4%-4.8%]); the overall annualized rate was 2.1% per patient-year (confidence interval, 1.2%-3.3%). Seventeen patients (94%) were treated conservatively and 1 with surgery. Four patients (22%) died from endocarditis or complications to treatment, 2 of those (11%) during initial hospitalization for PVE. An increased risk of TAVI-PVE was seen in patients with low implanted valve position (hazard ratio, 2.8 [1.1-7.2]), moderate or worse postprocedural paravalvular regurgitation (hazard ratio, 4.0 [1.5-11]), implantation of >1 prosthesis (hazard ratio, 5.2 [1.5-18]), and any vascular complication (hazard ratio, 3.8 [1.5-9.8]). CONCLUSIONS: TAVI-PVE occurred at a slightly higher rate than reported for surgically implanted valves. Conservative treatment was associated with an acceptable outcome. Suboptimal valve deployment and vascular complications were associated with an increased risk of TAVI-PVE.

Trousseau syndrome with nonbacterial thrombotic endocarditis in a patient with uterine cancer.

This paper aims to describe the usefulness of transthoracic echocardiography in the follow-up of recurrent nonbacterial thrombotic endocarditis (NBTE) associated with neoplastic conditions. A 60-year-old woman with advanced uterine cancer developed recurrent areas of aseptic vegetation on the mitral valve along with cerebral, renal and splenic embolisms. Echocardiographic assessments revealed vegetation and thrombotic events on three occasions. In this case, transthoracic echocardiography was effective in following the decreased frequency of attachment of the NBTE vegetation to the mitral valve and reductions in the size of the area of vegetation following treatment with unfractionated heparin infusion, hysterectomy and chemotherapy.

Nonbacterial thrombotic endocarditis with ST-elevation myocardial infarction treated with percutaneous coronary aspiration thrombectomy.

ST-elevation myocardial infarction from coronary embolus is a rare complication of nonbacterial thrombotic endocarditis, with little data on therapeutic management. We present a novel use of percutaneous coronary aspiration thrombectomy using an Export(®) catheter resulting in successful restoration of normal coronary blood flow. We also demonstrated complete resolution of the thrombotic valvular lesion with double antiplatelet and anticoagulation therapy alone. The clinical manifestations and management of coronary embolisation from nonbacterial thrombotic endocarditis are reviewed.

Nonbacterial thrombotic endocarditis in pancreatic cancer.

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