# Perioperative Management of a Case of Trousseau Syndrome Accompanied by Aortic Valve Vegetation

## TL;DR

This paper discusses the challenges of managing a rare condition called Trousseau syndrome, highlighting the ineffectiveness of certain anticoagulants and the importance of monitoring and treating the underlying cancer.

## Contribution

The paper presents a case where direct oral anticoagulants were ineffective for Trousseau syndrome, suggesting continuous heparin and TEE monitoring as better alternatives.

## Key findings

- DOACs like Edoxaban were ineffective in preventing embolism in this Trousseau syndrome case.
- Continuous heparin infusion and TEE monitoring helped avoid unnecessary surgery and manage the condition.
- Underlying ovarian cancer was identified as the cause of Trousseau syndrome and NBTE.

## 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.