Non-bacterial thrombotic endocarditis: a highly dynamic entity with rapid response to initiation and discontinuation of heparin

Hypercoagulability in patients with active cancer is common and associated with increased morbidity and mortality. Marantic endocarditis or non-bacterial thrombotic endocarditis (NBTE) is a subtype and describes sterile platelet–fibrin vegetations on normal cardiac valves in patients with malignant disease. Recently, our group has published the ‘marantic kiss’ as a pathognomonic echocardiographic sign for NBTE. In this report, we present a 49 year-old female patient where detection of the ‘marantic kiss' in echocardiography initiated a thorough search for underlying malignant disease. Previously unknown endometrial cancer was consequently diagnosed. At the time of NBTE diagnosis, the patient had taken apixaban for 4 months due to initial pulmonary embolism. Extensive NBTE resolved completely within 5 weeks when switched to low-molecular-weight heparin (LMWH). Unfortunately, the patient was started again on apixaban, and the lesions had reoccurred 5 weeks later. Subsequent permanent switch to LMWH showed sustained resolution in 4 months follow-up (Figure). Not only NBTE lesions but also the associated aortic regurgitation (AR) was dynamic. In NBTE, AR is not due to valve destruction but to a coaptation defect caused by the thrombotic lesions located on the ventricular side of the tips of the cusps. This results in the characteristic ‘star-like’ appearance of the regurgitant jet along the commissural lines. Degree of regurgitation therefore correlates with the extent of NBTE. Funding: None declared. No new data were generated or analysed in support of this manuscript.