Article ID: CJ-22-0036
A 52-year-old woman with adenocarcinoma of the lung (stage IVB) was referred because of severe aortic stenosis (AS) causing dizziness and faintness.
She had been admitted to another hospital for acute cerebral infarction, deep vein thrombosis in the right soleal vein, and moderate AS (peak velocity <4.0 m/s) 6 months previously, and apixaban (10 mg/day) had been prescribed. Physical examination revealed blood pressure 128/72 mmHg, pulse rate 66 beats/min, a Levine grade 3 systolic murmur at the right sternal border of the 2nd intercostal space, and decreased respiratory sounds in the left lower lung field. Laboratory data were normal, including antiphospholipid antibody syndrome and other coagulation data, but there were high levels of D-dimer (3.6 μg/mL) and N-terminal probrain natriuretic peptide (993.3 pg/mL). Chest radiography showed mild cardiomegaly (cardiothoracic ratio, 51%) and left pleural effusion. ECG showed sinus rhythm and left ventricular hypertrophy (LVH). Transthoracic echocardiography revealed a thickened aortic valve with high echo-intensity (Figure A,B, arrows), severe AS with a peak velocity of 5.0 m/s (Figure C), which had progressed from the month before (peak velocity, 4.5 m/s), aortic valve area (0.71 cm2) and average pressure gradient (60 mmHg), as well as diffuse LVH with a left ventricular ejection fraction of 54%.
Transthoracic echocardiography (A, parasternal short-axis; B, apical 3-chamber; C, continuous wave Doppler tracing through the aortic valve), intraoperative finding of vegetation-like growth (D), and macroscopic (E) and microscopic (F) images of the thickened aortic valve.
Before starting chemotherapy, she underwent aortic valve replacement with a bioprosthetic valve. The intraoperative finding was a bicuspid aortic valve (fusion of the left and right coronary cusps) with moderately restricted mobility without sclerosis or calcification, but with vegetation-like material on the ventricular side of the aortic cusps (Figure D,E, arrows). The pathological finding was fibrin with inflammatory cells but no microorganisms on the surface of the valve (Figure F). Taken together, the findings indicated nonbacterial thrombotic endocarditis (NBTE). Clinician should keep in mind that NBTE can progress stenosis of the bicuspid aortic valve in cancer patients.
The authors have no conflicts of interest to declare.
