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      We thank Dr Watanabe for his interest in our work.
      • Zmaili MA
      • Alzubi JM
      • Kocyigit D
      • et al.
      A contemporary 20-year Cleveland Clinic experience of nonbacterial thrombotic endocarditis: etiology, echocardiographic imaging, management, and outcomes.
      To better illustrate the initial presentations and management strategies for our cohort of patients with nonbacterial thrombotic endocarditis (NBTE), a brief summary is shown in the Table.
      TableThe Cohort of Patients with NBTE Stratified According to the Initial Presentation and Management Strategy
      Initial Presentation
      Cerebrovascular accident (n = 25)Heart failure (n = 9)Acute coronary syndrome (n = 3)Other (n = 5)
      Conservative management19 (76%)7 (77.8%)2 (66.7%)4 (80%)
      Surgical management6 (24%)2 (22.8%)1 (33.3%)1 (20%)
      NBTE = nonbacterial thrombotic endocarditis.
      As highlighted by Dr Watanabe, NBTE often manifests as a cardioembolic event.
      • Asopa S
      • Patel A
      • Khan OA
      • et al.
      Non-bacterial thrombotic endocarditis.
      Two-thirds of patients (n = 28, 66.7%) presented this way in our study, with the cerebral (n = 25) and coronary circulations (n = 3) being the major targets.
      • Zmaili MA
      • Alzubi JM
      • Kocyigit D
      • et al.
      A contemporary 20-year Cleveland Clinic experience of nonbacterial thrombotic endocarditis: etiology, echocardiographic imaging, management, and outcomes.
      Heart failure symptoms and signs at presentation, which were also reported in prior case reports,
      • Muhammadzai HZU
      • Shavadia J
      • Okpalauwaekwe U
      • Haddad H
      Antemortem diagnosis of nonbacterial thrombotic endocarditis in a patient with previously resected pancreatic adenocarcinoma: a case report.
      ,
      • Vinales KL
      • Gopalan RS
      • Lanza LA
      • et al.
      Unusual case of nonbacterial thrombotic endocarditis attributable to primary antiphospholipid syndrome.
      were observed in 9 of 42 patients (21.4%) in our study.
      • Zmaili MA
      • Alzubi JM
      • Kocyigit D
      • et al.
      A contemporary 20-year Cleveland Clinic experience of nonbacterial thrombotic endocarditis: etiology, echocardiographic imaging, management, and outcomes.
      In terms of other presentations, these included vague symptoms or nonspecific signs as described in previous case reports,
      • Umeojiako WI
      • Kasouridis I
      • Sargent R
      • Ghani S
      Atypical marantic endocarditis.
      such as altered mental status, dizziness, and generalized weakness.
      Clinical practice guidelines regarding the surgical management of NBTE are lacking. Management of NBTE should be individualized in the context of underlying disease, and surgical management should be pursued only if there are clear indications for surgery, such as severe valvular dysfunction despite appropriate medical therapy, leading to heart failure, and persistent vegetations leading to recurrent embolism, after weighing the benefits and risks of surgery.
      • Asopa S
      • Patel A
      • Khan OA
      • et al.
      Non-bacterial thrombotic endocarditis.
      ,
      • Otto CM
      • Nishimura RA
      • Bonow RO
      • et al.
      2020 ACC/AHA Guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
      Following multidisciplinary review by the heart valve team, surgical management was pursued in 10 patients (6 patients presented with cerebrovascular accidents; 2 patients with heart failure; 1 with acute coronary syndrome; 1 with other presentation). It should be emphasized that, not only the initial presentation, but perhaps also more importantly, the presence of comorbidities, the risk of complications, and the individual patient's overall prognosis were key determinants of the ultimate management strategy.
      • Asopa S
      • Patel A
      • Khan OA
      • et al.
      Non-bacterial thrombotic endocarditis.

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        • et al.
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