Cancer‐associated non‐bacterial thrombotic endocarditis—Clinical series from a single institution

Abstract

Premortem clinical presentation of cancer‐associated non‐bacterial thrombotic endocarditis (Ca‐NBTE), therapy, and the clinal course is limited to case reports and small clinical series. An electronic search of Mayo Clinic records (03/31/2002–06/30/2022) with a subsequent manual review was performed to identify adult patients with echocardiographically detected NBTE and active malignancy, excluding those with infectious endocarditis or lupus anticoagulant/antiphospholipid antibodies. In this retrospective cohort study, we analyzed 115 Ca‐NBTE patients (mean age 63.2 ± 9.7 years, 66.1% female) involving 71 (61.7%) mitral, 58 (50.4%) aortic, 8 (6.9%) tricuspid, and 1 (0.9%) pulmonary valve. The most common cancer was lung (n = 45 cases (39.1%), followed by pancreatic (n = 19, 16.5%), gynecological (17, 14.8%), gastrointestinal (n = 10, 8.7%), and 10 (8.7%) with hematologic malignancy; 6 patients had two active cancers. Embolic complications at presentation were frequent: 94 (81.7%) brain, 11 splenic, 10 renal, 6 coronary, and 4 to the extremities. Of 104 anticoagulated patients, 60 received low molecular weight heparin, 17 unfractionated heparin, 16 apixaban, 8 warfarin, and 3 rivaroxaban. There were 18 arterial thromboembolisms; the Kaplan–Meier estimates of the incidence at 2 years were consistent with a rate of 15.9% [95% Confidence Interval (CI) 9.9–23.3], including 14 strokes (12.4%, 95%CI, 7.1–19.2), and 8 other arterial emboli (10.5%, 95%CI, 4.7–18.9); there were 10 venous thromboembolisms (8.9%, 95%CI, 4.5–15.0). Fourteen major bleedings occurred (12.8%, 95%CI, 7.3–19.9) and 94 patients died during follow‐up (77.9%, 95%CI, 71.1–85.8). Ca‐NBTE predominantly affected women with lung adenocarcinoma or digestive tract cancers and manifested by stroke with high mortality and frequent embolic and bleeding complications during anticoagulation therapy.

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

“…In this specific NBTE group of patients, both mitral and aortic valves are affected. As in the Ca-NBTE group [3], the majority of patients are women [14].…”

“…If left untreated, NBTE can lead to complications such as valvular dysfunction, heart failure, stroke, and systemic embolization [3,9]. The most common embolic complication occurs in the nervous system [3][4][5].…”

“…If left untreated, NBTE can lead to complications such as valvular dysfunction, heart failure, stroke, and systemic embolization [3,9]. The most common embolic complication occurs in the nervous system [3][4][5]. The pathogenesis involves a hypercoagulable state and the formation of fibrin-platelet thrombi on the altered valve, leading to valve fibrosis, distortion, and subsequent dysfunction [9,10].…”

“…NBTE presents with a heightened prevalence among females and is commonly associated with advancedstage cancers. Notably, lung cancer stands out as the predominant cause of cancer-associated NBTE (Ca-NBTE) [3][4][5]. Recent studies have indicated a significant association between COVID-19 and infectioninduced hypercoagulation persisting up to 180 days after the initial infection [6][7][8].…”