CONGRESS ABSTRACT

Patient presentation  A 52 years-old woman was admitted to the ER due to a complaint of left-sided hand clumsiness, with fluctuating dysesthesias. Routine blood work-up and Head CT scan were unremarkable. She was admitted to the local Stroke Unit. Initial work up  In the evening of day two left-sided hemiplegia with hemiattention with anosognosia was detected, therefore a urgent brain MRI was requested disclosing a massive bilateral acute stroke involving both occipital lobes and right MCA territory, suggesting an undisclosed embolic source (Fig.1) Diagnosis and Management  Transthoracic echocardiogram (TTE) was performed and showed the appearance of moderate aortic regurgitation (AR). Thus we decided to perform a transoesphageal echocardiogram (TEE) which disclosed the presence of two iso-hypoechoic oval-shaped formations attached with a broad implant base to the right coronary cusp (6×4 mm) and the left coronary cusp (3×3 mm), associated with severe AR. The images were suspicious for native aortic valve endocarditis. (Fig. 2) An Empiric antibiotic regimen was started. Given the stroke extension and the patient’s hemodynamic stability, heart surgery was deferred and a conservative approach advised. Follow-up  Blood cultures and serologic testing disclosed no abnormalities. An autoimmunity screening battery was negative. The CT scan disclosed splenic and bilateral kidney embolizations. She gradually recovered her vigilance and her motor deficits.  After 3 weeks a TEE was repeated and showed complete resolution of the aortic vegetations and a mild residual regurgitation. (Fig. 3). A subsequent FDG-PET /CT scan was negative. Conclusion(s)  The cardiological picture, therefore, seemed compatible with Non Bacterial Thrombotic endocarditis (NBTE), although up to that point it had not been possible to make a clear diagnosis of associated autoimmune/oncological pathology. Thus, the differential diagnosis with fibroelastoma could not be excluded. NBTE is a rare condition which is defined by formation of aseptic thrombi over non damaged heart valves, in the absence of bacteremia and mainly in association with hypercoagulable states.Cerebral as well as splanchnic embolization is not uncommon. With our clinical case we want to demonstrate the importance of carefully considering the need to subject a patient to irreversible cardiac surgery for valve replacement, in cases in which there is no clear etiological diagnosis and in which there is hemodynamic stability.