Diagnosis Of Nonbacterial Thrombotic Endocarditis Research Articles

Non-bacterial thrombotic endocarditis and pancreatic cancer: A literature review.

e24002 Background: Non-bacterial thrombotic endocarditis (NBTE) is a condition in which sterile vegetations are deposited on the cardiac valves, disrupting their function, and posing a risk for embolic stroke. It is a rare condition with rates in autopsy studies ranging from 0.9-1.6%1, and with some of the highest rates observed in patients with pancreatic cancer (PC).2 A review of PC-associated NBTE was conducted to improve our understanding and recognition of this rare but serious clinical entity. Methods: We performed a literature search in PubMed from database inception to November 2023 pairing keywords “Non-Bacterial Thrombotic Endocarditis”, “NBTE”, “Marantic Endocarditis”, “Sterile Endocarditis”, and “Libman-Sacks Endocarditis” with “Pancreatic Cancer”, “Adenocarcinoma of the Pancreas”, and “Neuroendocrine Pancreatic Cancer”. We also used the search term “Marantic Endocarditis associated with Pancreatic Cancer: A case series”. The database was filtered only for full text, English language, and human species. Results: We reviewed 17 studies and included 19 patients in this review. Diagnostic presentation included cerebral vascular accident (CVA) (n = 8), endocarditis (n = 3), or a thrombotic pathology such as deep venous thrombosis (DVT) or pulmonary embolism (PE) (n =4). NBTE (n = 12) was predominantly diagnosed before pancreatic cancer (n = 5). Echocardiography was positive for vegetations in most specified cases (14/15), blood cultures were negative in all specified cases (12/12), and abdominal imaging was consistent with pancreatic cancer in all specified cases (15/15). Metastatic disease was found in 13 out of 19 cases, with spread to liver (n = 13), lung (n = 2), and the adrenal glands (n = 1). Valvular localization identified mitral valve (n = 13), aortic valve (n = 7), and the tricuspid valve (n = 2). Treatment primarily focused on anticoagulation (n = 17), with low molecular weight heparin (n = 8) being the most common agent followed by unfractionated heparin (n = 6). 14 patients had expired by study publication, with 7 deaths occurring due to complications from pancreatic cancer and 2 occurring due to complications from NBTE. Conclusions: NBTE is a rare condition with non-specific presentation, with some of the highest rates seen in PC. Diagnosis of NBTE should prompt immediate treatment as per guidelines and investigation for an underlying malignancy. In PC, especially with metastatic disease, clinicians should maintain a low threshold to initiate an endocarditis work-up in the presence of neurologic symptoms or evidence of cardiac dysfunction. However, it is also important to note that 31% of NBTE cases occurred in the absence of metastatic PC, suggesting that even patients without advanced disease are at risk. Although NBTE associated with PC remains rare, given the severity of both conditions, clinicians should consider work-up for one disease process in the presence of the other.

PET-scan in diagnosis of non-bacterial thrombotic endocarditis: a case report

BackgroundNon-bacterial thrombotic endocarditis (NBTE), also known as marantic endocarditis or Libman–Sacks endocarditis, is a rare non-infectious condition affecting mostly the left-sided heart valves of patients who, most often, suffer from malignancies and connective tissue disorders. Herein, we present a case of a male patient with marantic endocarditis due to occult lung adenocarcinoma.Case presentationThe patient fulfilled the modified Duke’s criteria of possible bacterial endocarditis of the aortic valve; however, multiple blood cultures and serological tests were negative. In addition, the patient’s clinical course was constantly deteriorating. Thus, a fluorodeoxyglucose-positron emission tomography (FDG-PET) scan was conducted. This examination revealed multiple positive thoracic lymph node groups, as well as a positive lung lesion. The patient underwent aortic valve replacement and lymph biopsies during the operation established the diagnosis of solid/micropapillary lung adenocarcinoma and consequently of the non-bacterial thrombotic endocarditis.ConclusionsAdvanced imaging techniques may be needed to diagnose NBTE and should be kept in mind when the Duke criteria are not definite. Clinical suspicion is key to implement these premises. However, the exact role of the PET-scan has yet to be specified.

Isolated tricuspid valve disease in antiphospholipid syndrome

We report the case of a 27-year-old male, presenting with dyspnea and chest pain. Radiographic and echocardiographic evaluations revealed bilateral segmental pulmonary embolism, left lower extremity deep vein thrombosis, and isolated tricuspid valve endocarditis. Microbiologic and serologic tests ruled out an infectious etiology and supported a diagnosis of nonbacterial thrombotic endocarditis as a manifestation of a newly diagnosed antiphospholipid syndrome. We discuss the clinical presentation, diagnostic evaluations, treatment, and clinical outcome.

A Contemporary 20-Year Cleveland Clinic Experience of Nonbacterial Thrombotic Endocarditis: Etiology, Echocardiographic Imaging, Management, and Outcomes

BackgroundNonbacterial thrombotic endocarditis, or marantic endocarditis, is rare. Contemporary data on the etiology, echocardiographic evaluation, and management of nonbacterial thrombotic endocarditis are limited. MethodsA single-center retrospective cohort study was performed. Electronic medical records and echocardiographic records were searched for patients ages ≥18 years with a confirmed diagnosis of nonbacterial thrombotic endocarditis between January 1999 and November 2019. Demographic, echocardiographic, and management data were collected. ResultsOf 600,577 transthoracic echocardiograms (TTEs) and 89,264 transesophageal echocardiograms (TEEs), 42 patients had nonbacterial thrombotic endocarditis (mean age: 54 ± 14.5 years; 66.7% were female). The median duration of follow-up was 8.2 (interquartile range 3.3-24.4) months. Seventeen patients (40.5%) had malignancy, 33.3% had systemic lupus erythematosus, and 35.7% had antiphospholipid antibody syndrome. Stroke was the most common presentation (59.5%).TTE enabled the diagnosis in 19 cases (45.2%), compared with TEE, which identified the condition in 33 of 34 (97.1%) cases in which it was utilized. Three-dimensional echocardiography was performed in 17 TEEs. The most common valves involved were mitral (61.9%), and aortic (23.8%) valves. Thirty-two patients were managed with anticoagulation. Ten patients underwent surgery. Sixteen (38.1%) patients died, most of whom had a diagnosis of advanced malignancy. ConclusionIn a contemporary 20-year cohort, TTE and TEE played important roles in diagnosis, with superior diagnostic performance of TEE for nonbacterial thrombotic endocarditis. Mortality was high, and advanced malignancy portended a worse prognosis. Management in most cases was therapeutic anticoagulation. In select cases, surgery provided favorable outcomes.

Recurrent Stroke In 34 Year-Old, Unusual Presentation of Non-Bacterial Endocarditis

Factor V Leiden (FVL) and prothrombin G20210A (PGM) mutations are the most frequent genetic risk factors involved in deep venous thrombosis in Caucasians. Being heterozygous for both seems to increase the risk of venous events but it is not well established if the association increases the risk of arterial thrombosis or other thrombotic events. We present a case of recurrent stroke caused by non-bacterial thrombotic endocarditis (NBTE) in a 34-year-old Caucasian man heterozygous for both FVL and PGM. His diagnosis of NBTE was confirmed with pathology in the absence of other causes of NBTE.

Nonbacterial thrombotic endocarditis

An 83-year-old woman with a 10-year history of rheumatoid arthritis was admitted for urinary tract infection with exacerbation of chronic kidney disease and decompensated heart failure of unknown etiology. Transesophageal echocardiography (TEE) showed a vegetation involving the posterior mitral valve leaflet, and a hypothesis of infective endocarditis was proposed. Empirical antibiotic therapy was initiated. TEE was repeated after antibiotic therapy, and showed persistence of the original vegetation and revealed the presence of another, smaller vegetation. Clinical investigation revealed no infectious process, and so a diagnosis of nonbacterial thrombotic endocarditis (NBTE) was established. Anticoagulant therapy was started immediately. The NBTE lesion had disappeared on the follow-up echocardiogram two months after anticoagulant therapy.

Evaluation and Treatment of a Patient With Recurrent Stroke in the Setting of Active Malignancy.

Evaluation and Treatment of a Patient With Recurrent Stroke in the Setting of Active Malignancy.

MASSIVE STROKE ON ANTICOAGULATION; A CASE OF NONBACTERIAL THROMBOTIC ENDOCARDITIS IN A PATIENT WITH LUNG ADENOCARCINOMA

SESSION TITLE: Lung Cancer 1 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Non Bacterial Thrombotic Endocarditis (NBTE) is a rare condition that refers to noninfectious lesions of the heart valves. 80% of the cases are associated with advanced malignancy. When compared to other malignancies, higher rates are observed in patients with adenocarcinoma. (1) We present a case of massive stroke in a patient with NBTE secondary to Stage IV Lung Adenocarcinoma (LA) while on Apixaban. CASE PRESENTATION: 56y.o. male with no significant past medical history presented with abdominal pain and worsening shortness of breath. On further evaluation, he was noted to have splinter hemorrhages as well. Additional workup revealed multiple pulmonary nodules, hilar and mediastinal lymphadenopathy. A biopsy was obtained which was consistent with Lung Adenocarcinoma. PET Scan revealed metastatic activity in the neck and mediastinum. He was also found to have bilateral extensive Deep Vein Thrombosis in the lower extremities. Transesophageal Echocardiogram demonstrated a 3x4 mm mass on the anterior leaflet of the mitral valve. All infectious workup was negative and a diagnosis of NBTE was made. Treatment with low molecular weight heparin was discussed but patient refused, and consequently was sent home on Apixaban. Two weeks later, he was found down at his residence. Upon arrival to Emergency Department, he was noted to have complete left sided hemi neglect. Brain imaging revealed non-reversible ischemia in right Middle Cerebral Artery Territory. Mitral valve vegetation was the likely culprit. Computed Tomography (CT) of the head revealed hemorrhagic transformation. No further neurologic or cardiac intervention was performed. The patient was eventually discharged on Rivaroxaban and was instructed to follow up with his oncologist for initiation of chemotherapy. DISCUSSION: It's well known that low molecular weight heparin (LMWH) is the first choice for anticoagulation in NBTE secondary to malignancy, (1) nevertheless the patient refused it so he was placed on Apixaban instead, proving unfortunately to be ineffective. Anticoagulation with this medication has yet to be evaluated in patients with NBTE. Recent studies point out that Rivaroxaban and Edoxaban are comparable to (LMWH) in preventing Venous Thromboembolism and further embolic episodes caused by NBTE (2,3). CONCLUSIONS: Vegetations in NBTE vary in size from microscopic to large and exuberant. They can easily dislodge and cause embolic phenomena. LMWH, Rivaroxaban or Edoxaban should always be considered in these type of patients. Further investigation is required regarding other oral anticoagulants. We hope that clinicians can take our case as reference as properly managing these patients will have a dramatic impact on quality of live and even life expectancy. Reference #1: Mazokopakis EE, Syros PK, Starakis IK. Nonbacterial thrombotic endocarditis (marantic endocarditis) in cancer patients. Cardiovasc Hematol Disord Drug Targets 2010; 10:84. Reference #2: Gary E. et al. Edoxaban for the Treatment of Cancer-Associated Venous Thromboembolism. N Engl J Med 2018; 378:615-624 Reference #3: Young A. et al Anticoagulation Therapy in Selected Cancer Patients at Risk of Recurrence of Venous Thromboembolism: Results of the Select-D Pilot Trial. Thromb Res. 2016 Apr;140 Suppl 1:S172-3. DISCLOSURES: No relevant relationships by Girish Balachandran Nair, source=Web Response No relevant relationships by Fernando Figueroa Rodriguez, source=Web Response no disclosure on file for Hira Iftikhar

Nonbacterial thrombotic endocarditis - Not forgotten

We report the case of a 36-year-old man who presented with an incidental echocardiographic finding of a 1.1 × 0.8 cm mobile structure on the mitral valve associated with mild to moderate eccentric jet of mitral regurgitation. Surgical excision confirmed the diagnosis of nonbacterial thrombotic endocarditis (NBTE), formerly known as marantic endocarditis. The cardiolipin IgG and IgM antibodies and the lupus anticoagulant were strongly positive confirming the diagnosis of antiphospholipid syndrome. The patient was promptly anticoagulated. NBTE is a rare condition associated with advanced mucin secreting malignant tumours and hypercoagulable states. It is associated with high incidence of embolic events the most frequent ones being cerebral; the diagnosis is usually reached at post-mortem. Our case clearly demonstrates that vegetations on cardiac valves may pose a diagnostic dilemma and surgical intervention may be needed to reach a diagnosis. We propose that in patients with high likelihood of NBTE a transthoracic echocardiogram should be considered to assess for the above diagnosis which carries a high risk of life threatening embolic events. Anticoagulation or surgical excision is likely to improve cardiovascular outcome.

Stroke due to non-bacterial thrombotic endocarditis as initial presentation of breast invasive ductal carcinoma

We present a case of a 71-year-old woman with recurrent stroke episodes due to non-bacterial thrombotic endocarditis (NBTE) leading to the diagnosis of an early-stage breast carcinoma. NBTE is associated with a variety of inflammatory states, including malignancy. NBTE presents itself with systemic embolization, mostly stroke. Treatment consists of treating the underlying condition and start of systemic anticoagulation therapy. Cardiac surgery is restricted to highly selected cases, since prognosis usually is limited by the neoplasm, which usually is in an advanced stage at time of diagnosis of NBTE. The malignancy usually is diagnosed prior to NBTE. Cases presenting with NBTE leading to the diagnosis of malignancy, however, are rarely reported. To our knowledge, we present the first case leading to the diagnosis of an early-stage breast carcinoma.

Nonbacterial Thrombotic Endocarditis in a Child With Non-Hodgkin’s Lymphoma

The diagnosis of nonbacterial thrombotic endocarditis (NTBE) is rarely made during life. This report describes a child who had high-grade non-Hodgkin's lymphoma with NTBE and multiple systemic embolism. The transthoracic echocardiographic findings of mitral valve leaflet vegetations and progressive regurgitation led to surgical resection of the vegetations. A high index of suspicion is needed when a clinician is faced with a patient who has malignancy, systemic embolic phenomena, and persistent negative blood cultures.

Endocarditis trombótica no bacteriana y neoplasia pulmonar

A woman with the final diagnosis of non-bacterial thrombotic endocarditis associated to pulmonary adenocarcinoma is reported. She had had repetitive embolic strokes as the first manifestation, with vegetations on the mitral valve and without signs of acute infectious disease. The case is interesting because is an usually case of nonbacterial thrombotic endocarditis and the importance of an early diagnostic.

Nonbacterial Thrombotic Endocarditis with Recurrent Embolic Events as Manifestation of Ovarian Neoplasm

We describe the case of a 43-year-old woman with transient ischemic neurologic deficits and recurrent systemic and pulmonary emboli in whom infectious work-up and extensive thrombophilic evaluation were unremarkable. Transesophageal echocardiography (TEE) established the diagnosis of nonbacterial thrombotic endocarditis (NBTE). This is a rare condition often associated with hypercoagulable states or advanced malignancy such as adenocarcinomas, characterized by cardiac vegetations along valvular coaptation lines without destruction of leaflets. In our patient, we diagnosed an ovarian clear cell adenocarcinoma, a malignant disorder that has been rarely reported in association with NBTE. This case illustrates that NBTE can present as an atypical manifestation of malignancy and must be distinguished from infective endocarditis, which implies a different therapeutic strategy. When confronted with findings of NBTE without a clear etiology, an occult neoplasm must be excluded. Anticoagulant therapy is the mainstay of treatment. However, cardiac vegetations may require surgical intervention in rare instances.

Synchronous Primary Endometrial and Ovarian Carcinoma in a Patient With Marantic Endocarditis

Nonbacterial thrombotic endocarditis (NBTE), or marantic endocarditis, is a rare form of endocarditis found in patients with advanced malignancy and collagen-vascular disorders. There is limited information about the clinical course of patients with NBTE because the majority of cases are found at the time of autopsy. A 38-year-old woman presented to the emergency department with recent onset of chest pain and fatigue. Initial evaluation revealed cardiac valvular disease, and the patient underwent aortic valve replacement. Final pathology revealed nonbacterial thrombotic endocarditis. A metastatic work-up revealed a complex pelvic mass and elevated CA 125. The patient underwent an exploratory laparotomy and was subsequently found to have synchronous primary endometrial and ovarian carcinoma. Nonbacterial thrombotic endocarditis is rare and carries a high mortality. This case is unusual in that the diagnosis of nonbacterial thrombotic endocarditis led to the diagnosis of a gynecologic malignancy.

Antiphospholipid syndrome and right atrial mass

Clinical Summary A 43-year-old woman was urgently admitted to the hospital because of a syncopal episode. In the past she had had repeated spontaneous abortions, venous thrombotic events during pregnancy, and thrombocytopenia associated with lupus anticoagulant positivity. A diagnosis of antiphospholipid syndrome (APS) had been suggested 14 years earlier. Results of cardiac physical examination and a 12-lead electrocardiogram were unremarkable. Two-dimensional transthoracic and transesophageal echocardiography showed ventricular and left atrial chambers normal in size and function, whereas a polypus, mobile mass attached to the free wall was visualized in the right atrium (Figure 1, A and B ). Semilunar and atrioventricular valves were normal, without any evidence of vegetations. The patient underwent surgical removal of the mass, and pathologic examination ruled out a neoplastic or infective nature, by showing a fibrin network entrapping blood cells with calcific deposits at its implantation base (Figure 2). The histologic features were in keeping with an organized thrombosis, and a diagnosis of nonbacterial thrombotic endocarditis of the right atrial endocardium in the setting of APS was suggested. At 6 months’ follow-up, the patient is doing well with long-term anticoagulant therapy. She has no evidence of intracardiac mass recurrence on 2-dimensional echocardiography (Figure 1, C ). From the Institutes of Pathological Anatomy, Cardiovascular Surgery, and Rheumatology, University of Padua Medical School, Padua, Italy.

Stroke in patients with cancer: incidence and etiology.

To assess the incidence and type of strokes in patients with cancer at Memorial Sloan-Kettering Cancer Center. Retrospective review of all ischemic strokes diagnosed by a neurologist and confirmed by neuroimaging between February 1997 and April 2001 was conducted. Age, gender, cancer diagnosis and stage, and vascular risk factors were recorded. NIH Stroke Scale and modified Rankin Scale scores were calculated retrospectively. Stroke etiology was assigned independently by two neurologists using the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. Ninety-six patients with a confirmed stroke were identified. The median age was 67, and 61.5% were men. The distribution of vascular risk factors was comparable with that seen in large stroke trials. Lung cancer (30%) was the most common primary tumor followed by brain and prostate cancer (9% each). Strokes were embolic in 52 (54%) and nonembolic in 44 (46%). Eleven of 12 tested patients had an elevated D-dimer level, but in only 3 patients could a definitive diagnosis of nonbacterial thrombotic endocarditis be made. The median survival was 4.5 months (95% CI 2.8 to 9.5) from the diagnosis of stroke; 25% of patients died within 30 days. Treatment had no effect on survival. Embolic strokes are the commonest cause of stroke in patients with cancer, due partially to hypercoagulability, whereas atherosclerosis accounted for only 22% of stroke in this population. Outcome was primarily determined by the underlying malignancy and the patient's neurologic condition.

Echocardiography in nonbacterial thrombotic endocarditis: From autopsy to clinical entity

Bacteria-free verrucae, frequently termed “non-bacterial thrombotic endocarditis,” have been recognized in autoimmune disorders as well as in neo-plastic diseases. The antemortem diagnosis of non-bacterial thrombotic endocarditis is rare, and most existing data result from postmortem examinations. In 3 prospective echocardiographic studies we found typical cardiac valvular lesions in patients with primary antiphospholipid syndrome, myelo-proliferative disorders, and solid malignant tumors. Cardiac lesions associated with these 3 different entities had common echocardiographic appearance and correlated positively with thromboembolic events. The possibility of common pathogenesis is suggested, and clinical significance is discussed. (J Am Soc Echocardiogr 2000;13:876-81.)

Transient ischaemic attack in a young woman

A 35-year-old woman was admitted in March, 1997 because of sudden onset of right-sided weakness. Her medical history was unremarkable. Physical examination showed normal sinus rhythm, blood pressure 120/80 mm Hg, and a grade 2/6 systolic murmur over the precordium. The head, neck, lung, and abdomen were normal. On neurological examination, she was oriented and had upper motor neuron weakness grade 4/5 in the right upper and lower limb. Routine laboratory findings were normal. Computer tomographic scan of the brain, and transthoracic echocardiography and ultrasound of carotid arteries were normal. On the second hospital day, the patient’s power returned to normal and she was discharged taking aspirin 300 mg daily. She presented again 4 weeks later with multiple peripheral emboli of her right brachial and femoral arteries. The table shows results of laboratory tests. She underwent urgent embolectomy for the peripheral arterial occlusion, but developed bilateral cortical blindness caused by cerebral embolism. Transoesophageal echocardiography (TEE) showed a vegetation on the thickened aortic valves, which measured 0·7 cm by 1 cm. Culture of blood specimens and serological testing were negative. She was treated with intravenous antibiotics and heparin. Despite treatment with heparin, she developed multiple venous thromboses and subsequently died of massive pulmonary embolism two days later. Postmortem examination showed the presence of tumour in the right lower lobe of lung with multiple lymph nodes metastases. Multiple vegetations were found over the aortic, mitral, and tricuspid valves. Culture of vegetations was negative. History of the tumour showed poorly differentiated adenocarcinoma. Histology of the vegetations did not reveal any organism or malignant cells, which suggests the diagnosis of non-bacterial thrombotic endocarditis (NBTE). NBTE can complicate various malignant diseases, and is associated with an increase in morbidity and mortality as a result of systemic embolism. It is often not suspected until embolic events occur and is a rare antemortem diagnosis. The differential diagnosis of transient ischaemic attack in a young patient includes cardiogenic embolism due to atrial fibrillation, valvular heart disease, endocarditis and cardiac masses and tumour, and carotid artery stenosis. Rare causes are vasculitis, hypercoagulable status, primary antiphospholipid syndrome, CASE REPORT

Cardiac valvular vegetations in cancer patients: A prospective echocardiographic study of 200 patients

Nonbacterial thrombotic endocarditis can complicate various malignancies and may cause morbidity and mortality mainly as a result of systemic embolism. The antemortem diagnosis of nonbacterial thrombotic endocarditis is rare. The purpose of our study was to assess the frequency, echocardiographic characteristics, and clinical correlation of nonbacterial thrombotic endocarditis in cancer patients. A prospective echocardiographic screening of 200 nonselected ambulatory patients with solid tumors was performed. Patients were evaluated for evidence of thromboembolic events and for plasma D-dimer levels. A cohort of 100 consecutive patients without overt heart disease referred to echocardiography for the detection of an occult arterial embolic source served as a control group. It consisted of 52 males and 48 females, median age 60 years. The study group included 87 women and 113 men, median age 64 years (range 21 to 91). The frequent malignancies were lymphoma (26%), carcinoma of the gastrointestinal tract (20%), and carcinoma of the lung (16%). Cardiac valvular vegetations were found in 38 patients (19%) compared with only in 2 patients in the control group (2%, P < 0.001). Vegetations were found on the mitral or on the aortic valve in 19 and 18 patients, respectively. Isolated tricuspid valve vegetation was found in 1 patient. Valvular lesions were mostly common in patients with carcinoma of the pancreas (3 of 6, 50%), carcinoma of the lung (9 of 32, 28%), and lymphoma (10 of 52, 19%). Thromboembolism was diagnosed in 22 (11%) patients (12 deep vein thrombosis, 4 emboli to extremities, 2 cerebrovascular accidents, and 4 "silent" segmental left ventricular wall motion abnormalities on echocardiography). Thromboembolism was noticed in 9 of 38 patients (24%) with vegetations compared with 13 of 162 patients without vegetations (8%; P = 0.013). Plasma D-dimer level was examined in a subgroup of 170 patients. D-dimer level was increased in 19 of 21 patients (90%) with thromboembolism compared with 76 of 149 patients without thromboembolism (51%; P = 0.001). This study demonstrated a high prevalence of cardiac valvular lesions in patients with solid tumors. Vegetations were associated with thromboembolism. Plasma D-dimer level was significantly increased in patients with thromboembolism.

Non-bacterial thrombotic endocarditis associated with malignant disease: a clinicopathological study of 16 cases.

Among 2627 necropsies performed in the Sir Charles Gairdner Hospital, Perth, over a period of 11 years, 16 cases of non-bacterial thrombotic endocarditis (NBTE) were found in patients with cancer (13 adenocarcinomas). The final stay in hospital of seven of these patients was complicated by a major embolic cerebral (six patients), or spinal cord (one patient), stroke. In all cases, the diagnosis of NBTE was made at necropsy. The aortic valve was affected in 10 patients, the mitral valve in five, and both the mitral and tricuspid valves in one. The diagnosis of NBTE should be considered in any patient with a known, or suspected, malignant neoplasm who suffers a stroke or other unexplained embolic events.