ArticlePDF Available

Marantic or Non-Bacterial Thrombotic Endocarditis

Authors:
Viren Ahluwalia
Viren Ahluwalia
Viren Ahluwalia
  • This person is not on ResearchGate, or hasn't claimed this research yet.
Download full-text PDF
Read full-text
Download citation
Available via license: CC BY 4.0
Content may be subject to copyright.
Page 1 of 2
Introduction
Marantic endocarditis (MAE), “verrucous” or “Libman Sachs
Endocarditis” are all different synonyms of the nowadays agreed
term non-bacterial thrombotic endocarditis (NBTE), which is
    
infective endocarditis. MAE is associated with an autoimmune-
     
           
     
(SLE), but also in terminal malignancies. The incidence of MAE is
   

      
and management.
Aetiology and Pathophysiology
MAE is most commonly associated with malignancy with

cancer to adenocarcinoma of the lungs. Overall, adenocarcinomas
have been shown to be mostly associated with MAE and of those
    
       
        
       


The trigger for MAE and how it relates to commonly associated
       
  
       
       
      
         

Presentation and Diagnosis
       
       
cerebrovascular events, such as strokes or transient ischemic
attacks [6]. Emboli can ultimately affect any arterial system
        
acute mesenteric ischaemia [3]. Localisation of causation can be
        
      
         
with SLE may describe a history of rashes, arthralgia and renal
      

Valvular vegetations in MAE are usually small, broad based
         
        
       
   


       
      
       
rule autoimmune conditions such as SLE. As with conventional
        

over transthoracic [7] in demonstrating vegetations.
Management

        
studies. This is in stark contrast to infective endocarditis, which has


management of the underlying condition likely causing MAE [9].
     
     
       

ISSN: 2643-6884 DOI: 10.33552/OJCR.2019.01.000519
Online Journal of
Cardiovascular Research
Mini Review Copyright © All rights are reserved by Viren Ahluwalia
Marantic or Non-Bacterial Thrombotic Endocarditis
Viren Ahluwalia*, Walid Safwat and Michael Kuehl
Department of Cardiology, UK
*Corresponding author:      

Received Date: March 11, 2019
Published Date: March 27, 2019
This work is licensed under Creative Commons Attribution 4.0 License

Online Journal of Cardiovascular Research Volume 1-Issue 4
Citation: 
. .
Page 2 of 2
         
       
      
         
anticoagulants like direct thrombin or factor Xa inhibitors have


is common. Therefore, some investigators suggest anticoagulation

[10]. Surgery is not routinely recommended to treat MAE. However,
        

    

         
as it is associated with disseminated and advanced underlying
malignancy.
Conclusion
Figure 1: TOE Features: MAE most commonly affects the left
side of the heart, commonly involving the basal and mid portion
of the valve. Masses traditionally have irregular borders, variable
echo density and an absence of independent motion.
       
         
    
       
         
     

serial blood cultures to rule out infective endocarditis followed by
investigation and treatment of the underlying causative condition
      



          
  

Acknowledgement
None.


References
1.           
    

2.          


3. 
    

  
      

 

6.             
     

7.             
     
  

 


        
  

9.            
    

10.          
        

... 4 It has been described more often as a complication of antiphospholipid syndrome, systemic lupus erythematosus, and malignancy. 5 Strokes and other embolic complications are the most common presentation of marantic endocarditis. 5 The pathophysiology is not well understood and the management often involves treating the underlying condition and anticoagulation. ...
... 5 Strokes and other embolic complications are the most common presentation of marantic endocarditis. 5 The pathophysiology is not well understood and the management often involves treating the underlying condition and anticoagulation. 5 Cardiac magnetic resonance is a sensitive, non-invasive investigation for myocarditis. ...
Myocarditis in Crohn’s disease: a case report
Article
Full-text available
  • Jul 2020
Background Mobile valvular masses are often considered pathognomonic for infective endocarditis. We present a case of a young patient with mobile valvular masses in the context of myocarditis likely secondary to active ileal Crohn’s disease. Cardiac magnetic resonance (CMR) imaging was crucial in diagnosing and monitoring our patient. Case summary A 27-year-old woman presented with pleuritic chest pain, dyspnoea, and a 3-day history of fevers. She also reported a 2-month history of intermittent visual loss in her right eye. She had a history of histologically proven ileal Crohn’s disease, diagnosed 5 months prior. She was haemodynamically unstable on presentation. Abnormalities on a transthoracic echocardiogram necessitated a transoesophageal echocardiogram. After blood cultures were sent, the patient was commenced on empirical treatment for infective endocarditis with gentamicin and flucloxacillin. Eight days after her initial presentation, all blood cultures remained negative and she was changed to empirical treatment for culture negative endocarditis with ceftriaxone and vancomycin, according to local protocol. Despite 8 days of treatment for infective endocarditis she remained febrile. A CMR was organized on Day 9 and this showed myocarditis, which changed the treatment paradigm. She responded swiftly to steroids and anti-coagulation. Discussion In this case, echo-dense valvular lesions are not pathognomonic for infective endocarditis and a careful diagnostic process involving multi-modality imaging, including CMR, occurred to arrive at a diagnosis of myocarditis likely secondary to Crohn’s disease.
View
Malignant Peritoneal Mesothelioma: A Rare Cause of Ascites
Article
Full-text available
  • Oct 2018
Malignant peritoneal mesothelioma (MPM) is a rare diagnosis that presents with difficulties in diagnosis and management. This article reports a case of an 88-year-old male who presented with a 2-week history of abdominal distention and bloating. He worked at an insulation production factory between the ages of 23 and 25 years with presumed asbestos exposure. On the computed tomography scan of the abdomen/pelvis, the patient was found to have diffuse omental, peritoneal, and mesenteric nodularity with moderate to large ascites. Omental biopsy revealed MPM. The overall prognosis of MPM remains poor, with a median survival time of 12 months at the time of diagnosis. Treatment modalities offered in the United States include chemotherapy alone, cytoreductive surgery alone, or cytoreductive surgery/chemotherapy combination.
View
Libman-Sacks Endocarditis: Detection, Characterization, and Clinical Correlates by Three-Dimensional Transesophageal Echocardiography
Article
Full-text available
  • Mar 2015
Libman-Sacks endocarditis, characterized by Libman-Sacks vegetations, is common in patients with systemic lupus erythematosus and is commonly complicated with embolic cerebrovascular disease. Thus, accurate detection of Libman-Sacks vegetations may lead to early therapy and prevention of their associated complications. Although two-dimensional (2D) transesophageal echocardiography (TEE) has high diagnostic value for detection of Libman-Sacks vegetations, three-dimensional (3D) TEE may allow improved detection, characterization, and clinical correlations of Libman-Sacks vegetations. Twenty-nine patients with systemic lupus erythematosus (27 women; mean age, 34 ± 12 years) prospectively underwent 40 paired 3D and 2D transesophageal echocardiographic studies and assessment of cerebrovascular disease manifested as acute clinical neurologic syndromes, neurocognitive dysfunction, or focal brain injury on magnetic resonance imaging. Initial and repeat studies in patients were intermixed in a blinded manner with paired studies from healthy controls, deidentified, coded, and independently interpreted by experienced observers unaware of patients' clinical and imaging data. The results of 3D TEE compared with 2D TEE were more often positive for mitral or aortic valve vegetations, and 3D TEE detected more vegetations per study and determined larger sizes of vegetations (P ≤ .03 for all). Also, 3D TEE detected more vegetations on the anterior mitral leaflet, anterolateral and posteromedial scallops, and ventricular side or both atrial and ventricular sides of the leaflets (P < .05 for all). In addition, 3D TEE detected more vegetations on the aortic valve left and noncoronary cusps, coronary cusps' tips and margins, and aortic side or both aortic and ventricular sides of the cusps (P ≤ .01 for all). Furthermore, 3D TEE more often detected associated mitral or aortic valve commissural fusion (P = .002). Finally, 3D TEE detected more vegetations in patients with cerebrovascular disease (P = .01). Three-dimensional TEE provides clinically relevant additive information that complements 2D TEE for the detection, characterization, and association with cerebrovascular disease of Libman-Sacks endocarditis. Published by Elsevier Inc.
View
Libman-Sacks Endocarditis and Embolic Cerebrovascular Disease
Article
Full-text available
  • Sep 2013
The aim of this study was to determine whether Libman-Sacks endocarditis is a pathogenic factor for cerebrovascular disease (CVD) in systemic lupus erythematosus (SLE). A cardioembolic pathogenesis of SLE CVD manifested as: 1) neuropsychiatric systemic lupus erythematosus (NPSLE), including stroke and transient ischemic attacks (TIA); 2) neurocognitive dysfunction; and 3) magnetic resonance imaging of focal brain lesions has not been established. A 6-year study of 30 patients with acute NPSLE (27 women, 38 ± 12 years of age), 46 age- and sex-matched SLE controls without NPSLE (42 women, 36 ± 12 years of age), and 26 age- and sex-matched healthy controls (22 women, 34 ± 11 years of age) who underwent clinical and laboratory evaluations, transesophageal echocardiography, carotid duplex ultrasound, transcranial Doppler ultrasound, neurocognitive testing, and brain magnetic resonance imaging/magnetic resonance angiography. Patients with NPSLE were re-evaluated after 4.5 months of therapy. All patients were followed clinically for a median of 52 months. Libman-Sacks vegetations (87%), cerebromicroembolism (27% with 2.5 times more events per hour), neurocognitive dysfunction (60%), and cerebral infarcts (47%) were more common in NPSLE than in SLE (28%, 20%, 33%, and 0%) and healthy controls (8%, 0%, 4%, and 0%, respectively) (all p ≤ 0.009). Patients with vegetations had 3 times more cerebromicroemboli per hour, lower cerebral blood flow, more strokes/TIA and overall NPSLE events, neurocognitive dysfunction, cerebral infarcts, and brain lesion load than those without (all p ≤ 0.01). Libman-Sacks vegetations were independent risk factors of NPSLE (odds ratio [OR]: 13.4; p < 0.001), neurocognitive dysfunction (OR: 8.0; p = 0.01), brain lesions (OR: 5.6; p = 0.004), and all 3 outcomes combined (OR: 7.5; p < 0.001). Follow-up re-evaluations in 18 of 23 (78%) surviving patients with NPSLE demonstrated improvement of vegetations, microembolism, brain perfusion, neurocognitive dysfunction, and lesion load (all p ≤ 0.04). Finally, patients with vegetations had reduced event-free survival time to stroke/TIA, cognitive disability, or death (p = 0.007). The presence of Libman-Sacks endocarditis in patients with SLE was associated with a higher risk for embolic CVD. This suggests that Libman-Sacks endocarditis may be a source of cerebral emboli.
View
Nonbacterial Thrombotic Endocarditis in Cancer Patients: Pathogenesis, Diagnosis, and Treatment
Article
Full-text available
  • Jun 2007
Learning Objectives Enumerate procoagulant factors present in malignancy and the risk for thromboembolic events. Describe the morbidity associated with nonbacterial thrombotic endocarditis. List the recommended evaluations and treatments for nonbacterial thrombotic endocarditis. CME Access and take the CME test online and receive 1 AMA PRA Category 1 Credit™ at CME.TheOncologist.com
View
Libman-Sacks Endocarditis in Systemic Lupus Erythematosus: Prevalence, Associations, and Evolution
Article
Full-text available
  • Aug 2007
We evaluated the prevalence and progression of Libman-Sacks endocarditis in patients with systemic lupus erythematosus and any association between this valvulopathy and their clinical and laboratory characteristics. Doppler echocardiography was performed in 342 consecutive patients with systemic lupus erythematosus (297 females and 45 males). The clinical and laboratory data were recorded. Patients were reevaluated after a follow-up period of 4 years. Libman-Sacks endocarditis was found in 38 patients (11%). In 24 of 38 patients, mitral valve involvement was found, resulting in regurgitation in all (mild in 18, moderate in 4, and severe in 2), whereas stenosis co-occurred with regurgitation in 9 patients (mild in 6 and moderate in 3). Thirteen (34%) of 38 patients had aortic valve involvement; 11 had regurgitation (mild) and 8 had stenosis (mild), coexistent with regurgitation in 6 of them. One patient had mild tricuspid regurgitation. A significant association was found between Libman-Sacks endocarditis and disease duration and activity, thromboses, stroke, thrombocytopenia, anticardiolipin antibodies, and antiphospholipid syndrome. During the follow-up period, 252 of 342 patients were reevaluated echocardiographically. Among the 38 patients with Libman-Sacks vegetations, 5 with mild mitral regurgitation at the beginning developed moderate (n=4) and severe mitral regurgitation (n=1), 2 patients with mitral stenosis (mild in 1 and moderate in 1) developed severe mitral regurgitation, and 2 patients with mild aortic regurgitation developed moderate and severe mitral regurgitation, whereas a significant deterioration of aortic stenosis was found. Two patients who were candidates for surgery died. Among the 213 patients without vegetations at the beginning, 8 developed new Libman-Sacks lesions. Libman-Sacks vegetations can be found in approximately 1 of 10 patients with systemic lupus erythematosus, and they are associated with lupus duration, disease activity, anticardiolipin antibodies, and antiphospholipid syndrome manifestations. A progression of valve lesions may occur during long-term follow-up.
View
View
Non-bacterial thrombotic endocarditis: clinicopathologic correlations
Article
  • Jan 1977
  • AM HEART J
Sixty-five cases of nonbacterial thrombotic endocarditis (NBTE) were discovered at autopsy during a 10 year period--an incidence of 1.6 per cent in the adult autopsy population. In 51 cases, one or more malignant neoplasms were associated; adenocarcinoma represented the most frequent histologic type of related neoplasm. Coagulation abnormalities suggestive of disseminated intravascular coagulation (DIC) were present in 18.5 per cent of the cases. It is possible that both the valvular and peripheral intravascular thromboses in at least some cases of NBTE represent the abnormal coagulation of DIC. Arterial thrombosis with infarction occurred in many peripheral organs. Splenic and renal were most frequent, but cerebral and cardiac consequences were the most significant.
View
Non-bacterial thrombotic endocarditis in cancer patients
Article
  • Feb 1991
  • ACTA CARDIOL
A total of 10 cases of non-bacterial thrombotic endocarditis (NBTE) were found among 1640 adult patients, autopsied in a 24-year period. Eight out of 10 patients had an underlying malignant tumor, NBTE was more common in cancer patients than in patients without malignancy (1.25% vs 0.2%, P less than 0.05). Patients with adenocarcinoma were at higher risk than patients with other malignant processes (2.70% vs 0.47%, P less than 0.05); especially in cases of pancreatic cancer in comparison with other kinds of adenocarcinoma (10.34% vs 1.55%, P less than 0.05). Systemic embolization was the main cause of morbidity. Any thromboembolic event in cancer patients should prompt a search for NBTE. NBTE may be present in undisseminated cancers in otherwise curable patients.
View
Trousseau's syndrome. Devastating coagulopathy in the absence of heparin
Article
  • Nov 1985
  • AM J MED
Two patients with Trousseau's syndrome experienced frequently recurring concomitant arterial and venous thrombotic events that resulted in sequential amputation and loss of the lower extremities. Serial examination of the blood in the patients demonstrated that these devastating thrombotic events were preceded by severe disseminated intravascular coagulopathy that occurred within an interval of a few hours. Warfarin therapy was without effect in preventing the occurrence of these events. Both patients demonstrated the absolute need for intravenous heparin, which effectively prevented the thrombotic events; when it was discontinued, the immediate consequences were disastrous and resulted in death. Techniques for long-term outpatient heparin therapy are discussed.
View
Recurrent Embolism in the Course of Marantic Endocarditis
Article
  • Jul 2005
Marantic or nonbacterial thrombotic endocarditis (NBTE) associated with systemic embolism is usually a complication of advanced or terminal malignancies. We report on the case of a 46-year-old woman in whom nonbacterial thrombotic endocarditis (NBTE)-related cerebral embolism was the first clinical sign of ovarian neoplasm, which was diagnosed after cardiac surgery. Marantic endocarditis should alert the physician to make every effort to diagnose the possible background of this clinical phenomenon. Early identification of NBTE, treatment of the underlying disease, and the associated coagulopathy could possibly prevent cardiac surgery.
View