Diagnostic Work-Up in Patients with Nonbacterial Thrombotic Endocarditis

Abstract

Nonbacterial thrombotic endocarditis (NBTE) is a form of endocarditis that occurs in patients with predisposing conditions, including malignancies, autoimmune diseases (particularly antiphospholipid antibody syndrome, which accounts for the majority of lupus-associated cases), and coagulation disturbances for which the correlation with classical determinants is unclear. The condition is commonly referred to as "marantic", "verrucous", or Libman-Sacks endocarditis, although these are not synonymous, representing clinical-pathological nuances. The clinical presentation of NBTE involves embolic events, while local valvular complications, generally regurgitation, are typically less frequent and milder compared to infective forms of endocarditis. In the past, the diagnosis of NBTE relied on post mortem examinations, while at present, the diagnosis is primarily based on echocardiography, with the priority of excluding infective endocarditis through comprehensive microbiological and serological tests. As in other forms of endocarditis, besides pathology, transesophageal echocardiography remains the diagnostic standard, while other imaging techniques hold promise as adjunctive tools for early diagnosis and differentiation from infective vegetations. These include cardiac MRI and ¹⁸FDG-PET/CT, which already represents a major diagnostic criterion of infective endocarditis in specific settings. We will herein provide a comprehensive review of the current knowledge on the clinics and therapeutics of NBTE, with a specific focus on the diagnostic tools.

Keywords: Libman–Sacks; anticoagulants; antiphospholipid antibodies; cardiac imaging; coagulopathy; echocardiography; immunology; marantic; non-infective endocarditis.

Figure 1

Proposed diagnostic algorithm for suspect NBTE. List of abbreviations—CT: computed tomography; MRI: magnetic resonance imaging; NBTE: nonbacterial thrombotic endocarditis; PCR: polymerase chain reaction; TTE/TEE: transthoracic/transesophageal echocardiogram.