Lupus valvulitis necessitating double valve replacement

Mitral valve surgery for mitral regurgitation caused by Libman-Sacks endocarditis: a report of four cases and a systematic review of the literature

Libman-Sacks endocarditis of the mitral valve was first described by Libman and Sacks in 1924. Currently, the sterile verrucous vegetative lesions seen in Libman-Sacks endocarditis are regarded as a cardiac manifestation of both systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). Although typically mild and asymptomatic, complications of Libman-Sacks endocarditis may include superimposed bacterial endocarditis, thromboembolic events, and severe valvular regurgitation and/or stenosis requiring surgery. In this study we report two cases of mitral valve repair and two cases of mitral valve replacement for mitral regurgitation (MR) caused by Libman-Sacks endocarditis. In addition, we provide a systematic review of the English literature on mitral valve surgery for MR caused by Libman-Sacks endocarditis. This report shows that mitral valve repair is feasible and effective in young patients with relatively stable SLE and/or APS and only localized mitral valve abnormalities caused by Libman-Sacks endocarditis. Both clinical and echocardiographic follow-up after repair show excellent mid- and long-term results.

Valvulitis requiring triple valve surgery as an initial presentation of systemic lupus erythematosus

Cardiac involvement is common in systemic lupus erythematosus. Classically, the term "verrucous endocarditis" was used to describe the noninfective vegetations seen on pathological inspection of heart valves. The wide use of echocardiography has led to increased frequency of detection of valve abnormalities, most commonly leaflet thickening. The vast majority of patients with systemic lupus erythematosus and valvular involvement are asymptomatic, with only a small minority progressing to hemodynamically significant pathology, generally after long disease duration. We report a patient with systemic lupus erythematosus and associated antiphospholipid syndrome, whose first presentation of disease consisted of severe, symptomatic valvular regurgitation of the mitral, aortic, and tricuspid valves requiring triple valve surgery.

Severe valvular regurgitation and antiphospholipid antibodies in systemic lupus erythematosus: A prospective, long-term, followup study

OBJECTIVE

To assess whether the presence of antiphospholipid antibodies is related to the incidence and progression of severe valvular dysfunction and the need for valve replacement in patients with systemic lupus erythematosus (SLE).

METHODS

In this prospective, long-term followup study, the initial echocardiographic findings in a cohort of 61 consecutive SLE patients were compared with those of 40 matched controls. All patients were serially evaluated for 14 +/- 3 years and had a followup echocardiogram 8 +/- 3 years after the initial evaluation. Serial determinations of anticardiolipin antibodies and lupus anticoagulant were performed in all cases.

RESULTS

The number of SLE patients with valvular abnormalities increased from 39% to 73% between the initial and the followup echocardiography, but only 7 patients (12%) developed severe valvular regurgitation. Severe valvular regurgitation was significantly associated with the presence of high levels of IgG anticardiolipin antibodies (P = 0.001). The combined incidence of stroke, peripheral embolism, need for valve surgery, and death was 86% in patients with severe valvular regurgitation, compared with 25% in those without (P = 0.003).

CONCLUSION

In SLE patients, the presence of high levels of IgG anticardiolipin antibodies is associated with the development of severe valvular regurgitation and with a high incidence of thromboembolic events and the need for valvular surgery.

Cardiovascular manifestations of systemic autoimmune diseases

The systemic autoimmune diseases are a protean group of illnesses that primarily affect the joints, muscles, and connective tissue. All aspects of the cardiovascular system can be involved with clinical consequences ranging from asymptomatic abnormalities to serious life-threatening conditions. This article discusses the cardiovascular manifestations of the systemic autoimmune diseases with particular focus on clinical pathophysiology and management.

[Successful surgical treatment of atrial septal defect with systemic lupus erythematosis in a 47-year-old female]

We report a case of surgical treatment of a 47-year-old female. She presented Atrial Septal Defect and Systemic Lupus Erythematosus. The operative procedure consisted of ASD's patch closure. Prednisolone was infused intravenously to prevent the acute deterioration of SLE after the operation. She was discharged from the hospital fifteen days after operation.

[Double heart valve replacement disclosing antiphospholipid syndrome]

In patients with systemic lupus erythematosus (SLE) heart valve lesions are usually discovered at echocardiography; their haemodynamic repercussions are uncommon, and valve replacement is exceptional. We report the case of a woman who had undergone aortic and mitral valve replacement before antiphospholipid antibodies were found associated with 4 ARA criteria of SLE. Histopathological examination confirmed the diagnosis of Libman-Sachs specific endocarditis. The presence of antiphospholipid antibodies leads to a discussion of their role in the physiopathology of the heart valve lesions and vascular accidents that occurred in this patient. The overlap observed between the diagnostic criteria of SLE and those of primary antiphospholipid syndrome is discussed. Heart valve lesions may be one of the modes of access to the antiphospholipid syndrome.

Infective endocarditis, rheumatoid factor, and anticardiolipin antibodies

Serum samples from 22 patients with infective endocarditis were analysed for the presence of antibodies to cardiolipin, false positive Venereal Disease Research Laboratory (VDRL) test, and rheumatoid factor in order to determine the prevalence of anticardiolipin antibodies, their level, and to ascertain whether there was any correlation with the presence of rheumatoid factor. Although the latex test was positive in 10/22 (45%) patients, anticardiolipin antibodies, usually of a low level, were raised in only four (18%), and the VDRL test was positive in two patients in whom other antibodies were negative. These results show a clear discordance between these three tests, indicating that B cell production of these antibodies is separate and distinct. As with other infections which result in anticardiolipin antibody production, no thrombotic events were encountered.

Clinically significant valvular heart disease in systemic lupus erythematosus

PURPOSE

Clinically significant valvular heart disease due to systemic lupus erythematosus (SLE) has generally been considered rare, and Libman-Sacks endocarditis has been thought to be predominantly an autopsy finding. With the declining prevalence of rheumatic heart disease, however, the spectrum of valvular heart disease is changing. We retrospectively analyzed our experience with SLE between 1975 and 1987 for the presence of hemodynamically significant valvular heart disease.

PATIENTS AND METHODS

An existing data base of 421 patients with SLE was selected for review. Patients were selected for inclusion in the study if they met four or more of the criteria of the American Rheumatism Association for SLE, they had clinically significant valvular heart disease, and tissue from the involved valve was available for review. The etiology of the valve lesion was determined by assessment of the clinical history, chart review, gross morphology, and valve histology.

RESULTS

Of 14 cases with pathologic material available for review, six had anatomic features of SLE valvular heart disease such as verrucous vegetations or valvulitis with necrosis and vasculitis. Two of these patients underwent successful valve replacements and four died from complications of their valve disease.

CONCLUSION

We suggest that significant morbidity and mortality may result from SLE valvular heart disease in about 1 to 2 percent of SLE patients and that the pathogenetic mechanisms underlying valve dysfunction in SLE patients are multifactorial.

Cardiovascular involvement in systemic lupus erythematosus

SLE is an inflammatory disease of unknown etiology with the potential of affecting virtually all organ systems. Cardiovascular involvement occurs frequently, although it is often mild enough not to cause clinical concern. Pericarditis is most commonly subclinical, noted only on echocardiogram. Pericardial fluid, which can accumulate rapidly enough to cause tamponade, is inflammatory in nature and can totally mimic infection. The occurrence of Libman-Sacks endocarditis, usually a pathological diagnosis of little clinical significance, has little if any correlation with the presence of audible murmurs. However, valve replacement is occasionally necessary secondary to sterile destruction. These valvular lesions can also embolize or become infected. The incidence of ischemic coronary disease is increased, both secondary to premature atherosclerosis and, rarely, coronary arteritis. Conduction disease and arrhythmias are infrequently reported in adult patients, but congenital CHB has been noted in children born to mothers who have circulating anti-Ro antibody. Evidence is accumulating that suggests there is a mild cardiomyopathy associated with SLE that may be due to thrombotic or inflammatory microvascular coronary disease. Acute clinical myocarditis also rarely occurs. Therapeutically, at present, a reasonable course would seem to be to limit all known possible contributing factors to premature coronary artery and myocardial disease (hypertension, hypercholesterolemia, smoking, steroid therapy, etc), to be vigilant about recognizing the rarer complications associated with SLE (infectious pericarditis and endocarditis, coronary arteritis, pericardial tamponade, clinical myocarditis), and to remember that these uncommon complications are indeed uncommon. The importance of vigorously treating systemic hypertension cannot be overstressed.

Cardiovascular manifestations of systemic lupus erythematosus

SLE affects most aspects of cardiac function, and recent studies have reported increasing cardiovascular morbidity and mortality. Pathologically, SLE is characterized by a pancarditis involving pericardium, myocardium, endocardium, and coronary arteries. In autopsy series, pericarditis has been found in 43% to 100% (mean 62%, Table I), and myocarditis was found in 8% to 78% (mean 40%, Table II), but both have been underdiagnosed clinically. Libman-Sacks lesions have been noted in 25% to 100% (mean 43%) and infective endocarditis in 1.1% to 4.9% of clinical and autopsy studies (Table III). Coronary disease may be due to arteritis, which should be treated with high-dose steroids, or it may be due to atherosclerosis, which is amenable to medical or surgical therapy. Valvular disease has been treated surgically, but with a combined surgical mortality as high as 25%. Aortic insufficiency and mitral regurgitation are the most common valvular problems, although aortic and mitral stenosis have also been reported. Hypertension has been noted in 14% to 69%, and heart failure in 5% to 44%. Evidence for a lupus cardiomyopathy, which may be subclinical, is reviewed. While steroids may ameliorate SLE pancarditis, they have also been associated with hypertension, LV hypertrophy, purulent and constrictive pericarditis, mitral regurgitation, and perhaps accelerated atherosclerosis. It remains to be seen if improved diagnosis and treatment of the cardiovascular manifestations of SLE can enhance survival.

Cardiovascular manifestations in systemic lupus erythematosus. Prospective study of 100 patients

One hundred consecutive female patients with active systemic lupus erythematosus (SLE) were studied from the cardiovascular point of view by means of non invasive methods. Seventy percent of the cases presented some type of cardiovascular anomaly. Seventy four percent of the resting electrocardiograms were abnormal as well as 72% of the M mode echocardiograms and 55% of the cardiac X ray series. The most frequent observed complications were: pericarditis and or pericardial effusion (39%), arterial hypertension (22%), ischemic heart disease (16%), myocarditis (14%), congestive heart failure (10%), pulmonary hypertension (9%), valvular heart disease (9%), pleural effusion (7%) and cerebro vascular accident (3%). We analyzed each one of these complications and found of special interest the high incidence of ischemic heart disease which is more frequent than has been hitherto reported. Ischemic heart disease was observed in two types of patients: a) Those with long term steroid therapy. In these, the mechanism seems to be an atherosclerotic disease probably induced by the chronic use of steroids. The management of these cases do not differ from other types of coronary heart disease due to atherosclerosis. b) Those with frank episodes of vasculitis in whom the basic mechanism is an inflammatory process of the coronary arteries and its treatment is fundamentally that of the vasculitis. We consider necessary to study routinely all patients with SLE through non invasive cardiological methods.

Aortic and mitral insufficiency complicating fulminant systemic lupus erythematosus

The cardiac complications of systemic lupus erythematosus (SLE) include a multitude of valvular, myocardial, and pericardial abnormalities resulting from acute and chronic inflammation involving the endocardium, myocardium, and/or pericardium. A case of acute, severe, aortic, and mitral insufficiency occurring as discrete complications of consecutive flares of SLE in the same patient is described with particular emphasis on the clinical and gross pathologic findings. The cardiac complications of SLE, both from a pathologic and clinical standpoint, are reviewed in the context of the uniqueness of this case.

Induction of fibroblast proliferation by human mononuclear leukocyte-derived proteins

Human peripheral blood mononuclear leukocytes stimulated by T cell antigen or mitogen release soluble factors that induce mitogenesis of dermal fibroblasts in vitro. Fractionation of supernatants from antigen-stimulated mononuclear leukocyte cultures by Sephadex G-100 yielded 2 major peaks of fibroblast proliferation activity (approximately 60,000 and approximately 16,000 MW). Both proliferation factors are heat stable (56 degrees C for 45 minutes) proteins. These data show that mononuclear leukocytes, under appropriate conditions, can release soluble mediators that can stimulate fibroblast proliferation; such leukocytes may also play a role in expanding fibroblast populations adjacent to certain cell-mediated immune reactions in vivo.