Presentation, Treatment, and Outcomes of Non-bacterial Thrombotic Endocarditis in Pancreatic Cancer: A Systematic Review.

Non-bacterial thrombotic endocarditis (NBTE) is characterized by the formation of sterile vegetations on cardiac valves, typically in the setting of malignancy or systemic inflammatory states. These vegetations can cause valvular dysfunction and have a higher tendency to embolize relative to other vegetations, which may result in life-threatening complications. Some of the highest rates of malignancy-associated NBTE have been seen in pancreatic cancer. A review of the literature on pancreatic cancer-associated NBTE was conducted to better understand patient presentation, disease course/progression, treatment, and outcomes. PubMed/MEDLINE was searched using terms related to NBTE and pancreatic cancer. Seventeen studies comprising 19 patients met the inclusion criteria. In 70% of cases, NBTE-related complications prompted the initial diagnosis, whereas pancreatic cancer was the presenting diagnosis in 30%. Valvular involvement most commonly affected the mitral valve (59%), followed by the aortic (32%) and tricuspid (9%) valves. NBTE occurred in the setting of metastatic pancreatic cancer in 68% of patients. Overall mortality was 93% at the time of publication, with death primarily attributable to pancreatic cancer (78%) rather than NBTE itself (22%). Among anticoagulation strategies, mortality was 100% in patients treated with unfractionated heparin and 85.7% in those receiving low-molecular-weight heparin. Given the high mortality and variable clinical picture, there should be a low threshold to initiate NBTE work-up in the presence of pancreatic cancer, regardless of cancer stage.