Prolonged Antibiotics Versus Prolonged Anticoagulation: A Case Report of Libman-Sacks Endocarditis

Marantic endocarditis, also known as nonbacterial thrombotic endocarditis (NBTE), Libman-Sacks endocarditis, or verrucous endocarditis, is a rare, non-infectious endocarditis (IE) that primarily affects the aortic and mitral valves. It is often underreported due to its subtle nonspecific presentation and close echocardiographic resemblance to infective endocarditis (IE). Substantial NBTE differentials include cardiac tumors, IE, and prior residual lesions. Echocardiography, clinical evaluation, and other alternative imaging modalities, such as cardiac CT or PET/CT, are essential for comprehensive assessment. Treatment options primarily focus on managing the underlying condition and preventing thromboembolic events. As NBTE is characterized by sterile vegetations on cardiac valves and is not caused by an infectious agent, antibiotics have no role in treating NBTE. Anticoagulation is a critical component of treatment in patients with NBTE. However, the recommended duration of anticoagulation is not known and is a case-based decision. The American College of Chest Physicians guidelines suggest that patients with NBTE and systemic or pulmonary emboli should be treated with full-dose intravenous unfractionated heparin or subcutaneous low molecular weight heparin. It is suggested that anticoagulation should continue until the vegetation resolves (median of 11 months) or for at least one to two years to mitigate the systemic embolic risks.