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• W1994889887 abstract "We report a 29-year-old patient who underwent right femoropopliteal bypass 2 years previously for right leg ischemia and was admitted recently to the hospital for acute myocardial infarction secondary to nonbacterial thrombotic endocarditis. A 29-year-old man was admitted to an emergency department with acute onset chest pain. His electrocardiogram showed typical anterior acute myocardial infarction with remarkable ST segment elevations. Emergency coronary angiography was performed, which revealed a complete occlusion of the proximal left anterior descending artery. The right and circumflex arteries were entirely normal. After anticoagulation with heparin and abciximab, the occlusion was crossed and the clot was aspirated through an aspiration catheter. The vessel was successfully stented with a good result. The patient's medical history included a big toe amputation because of ischemia and femoropopliteal bypass surgery 2 years ago, at which time Burger disease was diagnosed. He did not have any other medical history except for cocaine use. An echocardiogram was performed the following day, which showed a 21 × 14-mm irregularly shaped mass on the noncoronary leaflet of the aortic valve and a mobile mass measuring 10 × 6 mm in the left ventricular outflow tract (Figure 1). Severe aortic regurgitation was also found with a left ventricular ejection fraction of 35%. Because it was highly probable that the mass was a source of thromboembolization, an urgent aortic valve replacement with a 25-mm bileaflet mechanical valve was performed on the fourth day after acute myocardial infarction. During surgery, the mass was found along the coaptation line on the noncoronary leaflet of the aortic valve. There was some thrombus on the surface of the mass (Figure 2). The aortic valve was tricuspid with an apparently small noncoronary cusp, and there was some thickening at its base. The subsequent coagulation profiles were normal and immunology test results, including lupus anticoagulant antibodies, anticardiolipin antibodies, and rheumatoid factor and cultures, were negative. The pathologic results of the mass and aortic valve found no infectious cause but did show evidence of thrombus. We concluded that the patient's aortic valve lesion was nonbacterial thrombotic endocarditis. His postoperative course was uneventful, and he was discharged with oral anticoagulation therapy. Nonbacterial thrombotic endocarditis, previously known as marantic endocarditis, is most commonly seen in patients with advanced malignant disease and hypercoagulative state. It is described as a sterile vegetation composed of platelets and fibrin that adhere to valvular structures, most commonly found along coaptation lines, and is susceptible to embolization.1Borowski A. Ghodsizad A. Cohnen M. Gams E. Recurrent embolism in the course of marantic endocarditis.Ann Thorac Surg. 2005; 79: 2145-2147Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar, 2Patrick W.E. William D.E. Henry D.T. Robert D.M. Kenton J.Z. Surgical pathology of nonbacterial thrombotic endocarditis in 30 patients, 1985-2000.Mayo Clin Proc. 2001; 76: 1204-1212Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar In autopsy studies, evidence of embolization was found in approximately 40% of cases.2Patrick W.E. William D.E. Henry D.T. Robert D.M. Kenton J.Z. Surgical pathology of nonbacterial thrombotic endocarditis in 30 patients, 1985-2000.Mayo Clin Proc. 2001; 76: 1204-1212Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar In addition to advanced malignant disease, autoimmune disease and connective tissue disorder have been well-known predisposing factors for nonbacterial thrombotic endocarditis. Nonbacterial thrombotic endocarditis occurs both on pathologic valves and on relatively normal valves.3Kardaras F.G. Kardara D.F. Rotntoglani D.P. Sioras E.P. Christopoulou-Cokkinou V. Lolas C.T. et al.Acute aortic regurgitation caused by non-bacterial thrombotic endocarditis.Eur Heart J. 1995; 16: 1152-1154PubMed Google Scholar The most frequent underlying lesions include chronic rheumatic heart valve disease or nonspecific abnormality.3Kardaras F.G. Kardara D.F. Rotntoglani D.P. Sioras E.P. Christopoulou-Cokkinou V. Lolas C.T. et al.Acute aortic regurgitation caused by non-bacterial thrombotic endocarditis.Eur Heart J. 1995; 16: 1152-1154PubMed Google Scholar Patrick and colleagues2Patrick W.E. William D.E. Henry D.T. Robert D.M. Kenton J.Z. Surgical pathology of nonbacterial thrombotic endocarditis in 30 patients, 1985-2000.Mayo Clin Proc. 2001; 76: 1204-1212Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar reported a series of 30 patients who underwent valve replacement for nonbacterial thrombotic endocarditis: Eight patients (27%) had antiphospholipid syndrome; 6 patients (20%) had rheumatic heart valve disease; 2 patients (7%) had systemic lupus erythematosus; 2 patients (7%) had chronic rheumatoid arthritis; 9 patients (30%) had other underlying risk factors, such as congenital or degenerative heart valve disease or coagulation problem; and 3 patients (10%) had no risk factors. The majority of their patients underwent surgery for valve dysfunction. When patients can tolerate cardiac surgery with cardiopulmonary bypass, indications for surgery are valve dysfunction, recurrent embolic events,4Rabinstein A.A. Giavanelli C. Ricci M. Romano J.G. Koch S. Forteza A.M. Surgical treatment of nonbacterial thrombotic endocarditis presenting stroke.J Neurol. 2005; 252: 352-355Crossref PubMed Scopus (34) Google Scholar and mobile vegetation. Removal of vegetation and repair of the valve seem to be feasible if the vegetation is small and localized. Prognosis after valve replacement or repair for nonbacterial thrombotic endocarditis is unknown but depends on the underlying cause. Even if the previous femoropopliteal bypass was performed with the working diagnosis of Burger disease, it is unlikely because there was no arterial disease in the other leg. Because of the large size of the vegetation plus the possible delay of time between ischemic events,5Callander N. Rapaport S.I. Trousseau's syndrome.West J Med. 1993; 158: 364-371PubMed Google Scholar the patient's limb ischemia was thought to be arterial embolization caused by the vegetation. His noncoronary aortic leaflet was atrophic, which may be a factor in causing nonbacterial thrombotic endocarditis. Despite the patient's young age and good general condition, he should be monitored carefully for possible occult malignant disease. Nonbacterial thrombotic endocarditis should be considered when a patient presents with recurrent embolization in the absence of a history of malignant disease, hypercoagulative state, or atrial fibrillation. Surgical removal of the vegetation is effective to prevent further embolization, and valve replacement or repair may be essential to correct valve dysfunction." @default.
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• W1994889887 title "Acute myocardial infarction and limb ischemia as manifestation of nonbacterial thrombotic endocarditis" @default.
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