Near complete resolution of nonbacterial thrombotic endocarditis in a patient with antiphospholipid antibody syndrome

A 64-year-old woman with a medical history significant for cirrhosis, portal vein thrombosis on rivaroxaban, cerebrovascular accident, antiphospholipid antibody syndrome (APLS), and streptococcus mitis endocarditis with complete resolution underwent a routine screening transthoracic echocardiogram, which demonstrated new mitral valve vegetations on both the anterior and posterior leaflet tips with moderate-severe mitral valve regurgitation. A transesophageal echocardiogram dem onstrated irregular, mesoechoic, and mobile vegetations attached to the P2 (largest, 1.4×0.9 cm) and A2 leaflets (largest, 1.3×0.8 cm), with moderate-severe commissural regurgitation (Fig. 1). Further work-up ruled out infectious endocarditis and suggested nonbacterial thrombotic endocarditis (NBTE) as the underlying etiology. The patient was transitioned from rivaroxaban to warfarin. After 8 weeks of warfarin therapy, a repeat transesophageal echocardiogram was performed and showed complete resolution of the P2 leaflet vegetation, reduction in size of mass on the A2 leaflet (1.2×0.3 cm), and significant improvement in mitral regurgitation from moderate-severe to mild (Fig. 2). At the time of this report, she is currently maintained on warfarin therapy and is being monitored with serial transthoracic echocardiogram.