Abstract
There is no established consensus on the appropriate perioperative management of patients with Trousseau syndrome. In particular, the selection of anticoagulants, including direct oral anticoagulants (DOACs), remains a critical point. Current guidelines recommend continuous administration of unfractionated or low-molecular-weight heparin but do not specify the efficacy of DOACs. We report a case of Trousseau syndrome and nonbacterial thrombotic endocarditis (NBTE) with recurrent embolism, focusing on perioperative management and anticoagulant selection. In the case we encountered, a previously healthy woman presented with recurrent cerebral infarctions and was incidentally found to have an aortic valve mass, suggestive of papillary fibroelastoma. However, the planned resection of the aortic valve mass was canceled because transesophageal echocardiography (TEE) after the induction of general anesthesia confirmed its disappearance. The patient was discharged without thrombotic events but was readmitted three weeks later due to recurrent cerebral infarction. The embolisms recurred despite treatment with Edoxaban but improved with continuous heparin infusion, suggesting that DOACs were ineffective in this case. Further investigation revealed ovarian cancer, confirming Trousseau syndrome and NBTE as the underlying causes. Oophorectomy was performed, and no new ischemic events have occurred since. TEE evaluations were conducted at key decision-making points for surgery and other treatment strategies. In conclusion, DOACs may be ineffective in some cases of Trousseau syndrome and NBTE. Continuous heparin infusion, along with frequent TEE monitoring of valvular vegetation, may help avoid unnecessary valvular surgery and enable prioritization of treatment for the underlying disease.