Dados do Trabalho

Título

MARANTIC ENDOCARDITIS LEADING TO STROKE IN AN ONCOLOGIC PATIENT ON FULL ANTICOAGULANT DOSE: WHATS LEFT TO PREVENT NEW EVENTS?

RESUMO

CASE PRESENTATION: We present the case of a 79 year-old woman on treatment for a metastatic lung adenocarcinoma diagnosed upon bilateral pulmonary thromboembolism. She was started on apixaban 5mg BID and osimertinib. Six months later, she developed a severe stroke caused by an occlusive thrombus from right ICA to M1. She was submitted to mechanical thrombectomy, leaving a residual M1 occlusion, with partial recanalization. Transthoracic ecocardiogram showed mobile filamentar wooden images adhered to the right coronary and mitral valves, generating moderate reflux. Laboratory workup showed a hemolytic microangiopathic anemia with marked increase in D-dimers levels. Blood cultures were negative. She was followed with enoxaparin 1mg/kg BID, with no further vascular events. DISCUSSION: One in seven ischemic stroke patients can host occult cancers, with up to 20% of these being discharged as Embolic Stroke of Undetermined Source (ESUS). Marantic endocarditis (ME) is a proposed mechanism leading to stroke in oncologic patients. It is a rare condition and is strongly associated with lung adenocarcinoma. It usually damages healthy valves, leading to the formation of high-risk embolic thrombi. Permanent anticoagulation is warranted and surgical approaches are reserved for early disease in younger patients. Secondary prophylaxis with new direct oral anticoagulants (DOACS) lacks substantial evidence, with some studies citing edoxaban 60mg as a potential player. Vitamine K antagonists (VKA) are more accessible, but lack in patient safety due to interactions with chemotherapy plus higher bleeding rates. Enoxaparin is the most recommended by specialists, targeting final pathways in the coagulation cascade, but carries inconvenient logistics and administration. Since no absolute recommendation on the topic has been proposed, choosing an anticoagulation strategy in these patients envolves social, economic and technical issues as well as patient education. FINAL COMMENTS: Despite full dose anticoagulation, our patient still developed a major embolic event, highlighting the interface between cancer inflammation and thrombosis. Preventing vascular events in oncologic patients poses a true challenge, since their hyper coagulable state seems to be multifactorial and dynamic. Future studies should approach better stroke prevention strategies, keeping up with the current therapies that are improving cancer mortality and morbidity.

Palavras Chave

stroke, marantic endocarditis, anticoagulation