Cardiac involvement in patients with primary antiphospholipid syndrome

Cardiac involvement in the catastrophic antiphospholipid syndrome (CAPS): Lessons from the "CAPS registry"

OBJECTIVE

To analyze the demographic, clinical, and laboratory characteristics of catastrophic antiphospholipid syndrome (CAPS) patients with cardiac involvement, and to identify the factors associated with this cardiac involvement.

MATERIAL AND METHODS

Based on the analysis of the "CAPS Registry", the demographic, clinical, and serological characteristics of patients with cardiac involvement were analyzed. Cardiac involvement was defined as heart failure, valvular disease, acute myocardial infarction, pericardial effusion, pulmonary arterial hypertension, systolic dysfunction, intracardiac thrombosis, and microvascular disease. Univariate and multivariate analysis was used for multiple comparisons.

RESULTS

749 patients (293 [39 %] women and mean age 38.1 ± 16.2 years) accounting for 778 CAPS events were included, of them 404 (52 %) had cardiac involvement. The main cardiac manifestations were heart failure in 185/377 (55 %), valve disease in 116/377 (31 %), and acute myocardial infarction in 104/378 (28 %). Of 58 patients with autopsy/biopsy, 48 (83 %) had cardiac thrombotic microangiopathy, Stroke (29% vs. 21 %, p = 0.012), transient cerebral vascular accident (2% vs. 1 %, p = 0.005), pulmonary infarction (26% vs. 3 %, p = 0.017), renal infarction (46% vs. 35 %, p = 0.006), acute kidney injury (70% vs. 53 %, p < 0.001), and livedo reticularis (24% vs. 17 %, p = 0.016) were significantly more frequent during CAPS events with versus without heart involvement. Multivariate analysis identified acute kidney injury (OR 1.068, IC 95 % 1.8-4.8, p < 0.001) as the only clinical characteristics that were, independently, associated with cardiac involvement in CAPS events. Cardiac involvement was not related to higher mortality.

CONCLUSIONS

Cardiac involvement is frequent in CAPS, with association with kidney involvement, and it is not related to higher mortality. The presence of cardiac microthrombosis was demonstrated in most biopsies/autopsies performed.

Heart Valve Involvement in Patients with Antiphospholipid Syndrome: A Long-Term Follow-Up Study of a Single Centre

BACKGROUND

Valve involvement is the most common cardiac manifestation in antiphospholipid syndrome (APS). The objective of the study was to describe the prevalence, clinical and laboratory features, and evolution of APS patients with heart valve involvement.

METHODS

A retrospective longitudinal and observational study of all APS patients followed by a single centre with at least one transthoracic echocardiographic study.

RESULTS

144 APS patients, 72 (50%) of them with valvular involvement. Forty-eight (67%) had primary APS, and 22 (30%) were associated with systemic lupus erythematosus (SLE). Mitral valve thickening was the most frequent valve involvement present in 52 (72%) patients, followed by mitral regurgitation in 49 (68%), and tricuspid regurgitation in 29 (40%) patients. Female sex (83% vs. 64%; p = 0.013), arterial hypertension (47% vs. 29%; p = 0.025), arterial thrombosis at APS diagnosis (53% vs. 33%; p = 0.028), stroke (38% vs. 21%; p = 0.043), livedo reticularis (15% vs. 3%; p = 0.017), and lupus anticoagulant (83% vs. 65%; p = 0.021) were more prevalent in those with valvular involvement. Venous thrombosis was less frequent (32% vs. 50%; p = 0.042). The valve involvement group suffered from higher mortality (12% vs. 1%; p = 0.017). Most of these differences were maintained when we compared patients with moderate-to-severe valve involvement (n = 36) and those with no or mild involvement (n = 108).

CONCLUSIONS

Heart valve disease is a frequent manifestation in our cohort of APS patients and is associated with demographic, clinical and laboratory features, and increased mortality. More studies are needed, but our results suggest that there may be a subgroup of APS patients with moderate-to-severe valve involvement with its own characteristics that differs from the rest of the patients with mild valve involvement or without valve involvement.

Aortic valve surgery for aortic regurgitation caused by Libman-Sacks endocarditis in a patient with primary antiphospholipid syndrome: a case report

Background

Antiphospholipid syndrome is an antibody mediated pro-thrombotic state leading to various arterial and venous thromboses. The syndrome can be either primary or secondary to other autoimmune diseases, commonly systemic lupus erythematosus. Cardiac involvement, in particular valvular disease is common in patients with antiphospholipid syndrome, occurring in about a third of these patients. Valvular diseases associated with antiphospholipid syndrome often occur as valve thickening and non-bacterial vegetation or Libman-Sacks endocarditis. Deposits of antiphospholipid immunoglobulin and complement components are commonly observed in the affected valves, suggesting an inflammatory process resulting in valvular vegetation and thickening. Libman-Sacks endocarditis has a high propensity towards mitral valve, although haemodynamically significant valvular dysfunction is rare.

Case presentation

We present a successful aortic valve replacement with cardiopulmonary bypass in a 48 years old lady with antiphospholipid syndrome, who has severe aortic regurgitation as a result of Libman-sacks endocarditis. Antiphospholipid antibodies were positive and the clinical data showed both negative cultures and infective parameters. Surgically resected vegetations revealed sterile fibrinous and verrucous vegetations on aortic valve. Valve replacement and the course of cardiopulmonary bypass was uneventful, and the patient was discharged well.

Conclusions

Classically Libman-Sacks endocarditis is often and more commonly associated with autoimmune diseases such as systemic lupus erythematosus, although it can occur in both primary and secondary antiphospholipid syndrome. It is not a common entity, and it is a frequent underestimated disease as most clinicians do not routinely screen for valvular lesion in patients with antiphospholipid syndrome unless they are symptomatic. However, due to its high prevalence of cardiac involvement, clinicians should have a high index of suspicion in the attempt to minimize cardiovascular and haemodynamic complications. Valve surgery in patients with antiphospholipid syndrome carries considerable early and late morbidity and mortality, usually caused by thromboembolic and bleeding events. The perioperative anticoagulation management and haemostatic aspect of antiphospholipid syndrome present an exceptional challenges to clinicians, surgeons, anaesthetists and laboratory personnel.

Combined brain/heart magnetic resonance imaging in antiphospholipid syndrome-two sides of the same coin

Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by arterial, venous, and/or small vessel thrombosis, pregnancy morbidity, and persistently elevated levels of antiphospholipid antibodies (aPL). Cardiovascular disease (CVD) in APS can present as heart valvular disease (HVD), macro-micro-coronary artery disease (CAD), myocardial dysfunction, cardiac thrombi, or pulmonary hypertension. Brain disease presents as stroke or transient ischemic attack (TIA) and less frequently as cerebral venous thrombosis, seizures, cognitive dysfunction, multiple sclerosis (MS)-like syndrome, or chorea. Infarcts and focal white matter hyperenhancement are the commonest brain (MRI) abnormalities, while myocardial ischemia/fibrosis, valvular stenosis/regurgitation, or cardiac thrombi are the main abnormalities detected by cardiovascular magnetic resonance. This review aims to present the existing evidence on brain/heart involvement and their interrelationship in APS and the role of brain/heart MRI in their evaluation. Embolic brain disease, due to HVD, CAD, and/or cardiac thrombus, or brain hypo-perfusion, due to myocardial dysfunction, are among the main brain/heart interactions in APS and they are considered determinants of morbidity and mortality. Currently, there is no evidence to support the use of combined brain/heart MRI in asymptomatic APS patients. Until more data will be available, this approach may be considered in APS patients at high risk for CVD/stroke, such as systemic lupus erythematosus with high-risk aPL profile or high scores in CVD risk prediction models; APS patients with HVD/thrombus, CAD, or heart failure; those with classic and non-criteria neurologic APS manifestations (seizures, cognitive dysfunction, MS-like syndrome); or with aggressive multi-organ disease. Key Points • Cardiovascular disease (CVD) in antiphospholipid syndrome (APS) can present as heart valvular disease (HVD), macro-micro-coronary artery disease (CAD), myocardial dysfunction, cardiac thrombi, or pulmonary hypertension. • Brain disease presents as stroke or transient ischemic attack (TIA), and less frequently as cerebral venous thrombosis, seizures, cognitive dysfunction, and multiple sclerosis (MS). • A combined brain/heart MRI may be considered in APS patients at high risk for CVD/stroke, such as systemic lupus erythematosus with high-risk aPL profile or high scores in CVD risks; APS patients with HVD/thrombus, CAD, or heart failure; those with classic and non-criteria neurologic APS manifestations (seizures, cognitive dysfunction, MS-like syndrome); or with aggressive multi-organ disease.

Natural history of nonbacterial thrombotic endocarditis treated with warfarin

We report on the natural history of a cohort of patients presenting with transient ischemic attack or stroke and nonbacterial thrombotic endocarditis treated with warfarin.Patients with valvular vegetations on echocardiography, stroke, or transient ischemic attack presenting to a single neurologist were included. All patients were treated with warfarin until the vegetation resolved or for two years, then were switched to aspirin and had at least one clinical and echocardiographic follow-up.Twenty-nine patients were included and followed for a median of 27 months. Average age was 42 years and 72% were female. Two patients had vegetations on two valves. Five patients (17%) had recurrent strokes, three had systemic lupus erythematosus and antiphospholipid antibodies, one had antiphospholipid antibodies alone and one had neither condition. Three of the five patients did not have resolution of the vegetation at the time of the event. The valvular vegetations resolved in 23 of the 31 affected valves (74%) after a median of 11 months (range 4.5-157.5). Eleven patients had at least one follow-up echocardiogram after resolution of the vegetation and none had recurrent vegetations after warfarin was stopped.This study should serve to provide general recommendations regarding treatment of patients with TIA/stroke with nonbacterial thrombotic endocarditis. Valvular vegetations resolve in most patients and the risk of recurrent stroke is low. Warfarin can safely be switched to aspirin in most patients when the vegetation resolves or after two years if it does not resolve. Prolonged warfarin may be warranted in patients with systemic lupus erythematosus, positive antiphospholipid antibodies, and a persistent vegetation.

Cardiac Manifestations of Antiphospholipid Syndrome With Focus on Its Primary Form

Antiphospholipid syndrome (APS) is a multisystem autoimmune disease most commonly associated with recurrent arterial and venous thromboembolism and recurrent fetal loss. Other possible antiphospholipid antibody (aPL)-related clinical manifestations include cardiac involvement. The heart can be involved through immune mediated and /or thrombotic mechanisms. Mortality due to cardiovascular problems is elevated in APS. However, the cardiovascular risk in patients with primary APS (PAPS) compared with lupus-related APS is yet to be established. Cardiac symptoms of APS include valve abnormalities (thickening and vegetations), coronary artery disease (CAD), myocardial dysfunction, pulmonary hypertension, and intracardiac thrombi. Heart valve lesions are the most common cardiac manifestation, observed in approximately one third of PAPS patients and usually do not cause hemodynamic significance. Deposits of immunoglobulins including anticardiolipin (aCL), and of complement components, are commonly observed in affected heart valves from these patients. This suggests that an inflammatory process is initiated by aPL deposition, eventually resulting in the formation of valvular lesion. aPL may have a direct role in the atherosclerotic process via induction of endothelial activation. Multiple traditional and autoimmune-inflammatory risk factors are involved in triggering an expedited atherosclerotic arterial disease evident in APS. It is imperative to increase the efforts in early diagnosis, control of risk factors and close follow-up, in the attempt to minimize cardiovascular risk in APS. Clinicians should bear in mind that a multidisciplinary therapeutic approach is of paramount importance in these patients. This article reviews the cardiac detriments of APS, including treatment recommendations for each cardiac complication.

Current treatment of antiphospholipid syndrome: lights and shadows

For patients with antiphospholipid syndrome (APS), the consensus is to treat those who develop thrombosis with long-term oral anticoagulation therapy and to prevent obstetric manifestations by use of aspirin and heparin. These recommendations are based on data from randomized controlled trials and observational studies. Despite this body of knowledge, areas of uncertainty regarding the management of APS exist where evidence is scarce or nonexistent. In other words, for a subset of patients the course of management is unclear. Some examples are patients with 'seronegative' APS, those who do not fulfil the formal (clinical or serological) classification criteria for definite APS, and those with recurrent thrombotic events despite optimal anticoagulation. Other challenges include the treatment of clinical manifestations not included in the classification criteria, such as haematologic manifestations (thrombocytopenia and haemolytic anaemia), neurologic manifestations (chorea, myelitis and multiple sclerosis-like lesions), and nephropathy and heart valve disease associated with antiphospholipid antibodies (aPL), as well as the possible withdrawal of anticoagulation treatment in selected cases of thrombotic APS in which assays for aPL become persistently negative. This Review focuses on the current recommendations for thrombotic and obstetric manifestations of APS, as well as the management of difficult cases. Some aspects of treatment, such as secondary prophylaxis of venous thrombosis, are based on strong evidence--the 'lights' of APS treatment. Conversely, other areas, such as the treatment of non-criteria manifestations of APS, are based only on expert consensus or common sense and remain the 'shadows' of APS therapy.

Streptococcus agalactiae infective endocarditis with large vegetation in a patient with underlying protein S deficiency

We present a case of a patient with underlying protein S deficiency who suffered from infective endocarditis with a large anterior mitral leaflet (AML) mass of approximately 4.5 cm in length. Intraoperative transesophageal echocardiography (TEE) revealed the mass at the AML base and a rupture of the posterior mitral leaflet chordae tendinae. The vegetation's large size may have been caused by one or more of three factors: location, underlying disease, and the microorganism causing infection. Patients with protein S deficiency are prone to thromboembolic events during cardiac surgery. Infective endocarditis caused by Streptococcus agalactiae usually has a poor prognosis, and, thus, early surgery is recommended.

Task Force on Catastrophic Antiphospholipid Syndrome (APS) and Non-criteria APS Manifestations (I): catastrophic APS, APS nephropathy and heart valve lesions

The objectives of the 'Task Force on Catastrophic Antiphospholipid Syndrome (APS) and Non-criteria APS Manifestations' were to assess the clinical utility of the international consensus statement on classification criteria and treatment guidelines for the catastrophic APS, to identify and grade the studies that analyse the relationship between the antiphospholipid antibodies and the non-criteria APS manifestations and to present the current evidence regarding the accuracy of these non-criteria APS manifestations for the detection of patients with APS. This article summarizes the studies analysed on the catastrophic APS, APS nephropathy and heart valve lesions, and presents the recommendations elaborated by the Task Force after this analysis.

Atherosclerosis in primary antiphospholipid syndrome

Antiphospholipid syndrome (APS) is the most common cause of acquired thrombophilia, but experimental and clinical evidence accumulated over the years suggest that the clinical manifestations of APS go beyond those of a simple hypercoagulable state. Although still a controversial topic, the elevated risk of atherosclerosis in systemic lupus erythematosus seems little accounted for by the presence of antiphospholipid antibodies, whereas premature atherosclerosis has been addressed in few series of patients with primary APS. The available data in primary APS suggest that traditional risk factors for atherosclerosis are less involved in arterial disease, rather antiphospholipid antibodies appear as major players. Their effect on the coagulation system, the vessel wall and on the antioxidant/oxidant balance impairs vascular homeostasis, leading to premature arterial thickening.

The cardiac manifestations of antiphospholipid syndrome and their echocardiographic recognition

Antiphospholipid syndrome is an autoimmune disorder characterized by the presence of antiphospholipid antibodies, hypercoagulability, vascular thrombosis, and recurrent fetal loss. Cardiac involvement occurs frequently. Leaflet thickening and vegetations are detected quite often echocardiographically, but hemodynamically significant stenotic and/or regurgitant valvular disease is uncommon. Antiphospholipid syndrome can also cause left and right ventricular systolic and diastolic dysfunction as well as pulmonary hypertension. Other findings include spontaneous echo contrast and in situ mural thrombosis. In this review, the author discusses the major cardiac manifestations of antiphospholipid syndrome and highlights the role of echocardiography in their detection.

Tumors and tumor-like lesions of the heart valves

Valvular tumors and tumor-like lesions may have similar morphological and clinical characteristics, and may place the patients at a high risk of stroke in different ways. From January 2004 to June 2008, 11 patients underwent surgery for a suspected valvular tumor. Valvular tumor and tumor-like lesions accounted for 0.32% of adult cardiac operations. Five (45.5%) valvular lesions were papillary fibroelastomas, one (9.1%) was myxoma, 2 (18.2%) were organized thrombi, and 3 (27.3%) were calcification lesions. There was a total of 5 (45.5%) atrioventricular valve lesions, 4 arising from the atrial side of the leaflets, and one from the ventricular side. All 5 (45.5%) semilunar valvular lesions were from the aortic valve. One (9.1%) lesion originated from the chorda tendinea of the mitral valve. All leaflet lesions were resected by a simple shave technique, and all the patients recovered favorably. Valvular tumor and tumor-like lesions are rare. Pre-operative differential diagnoses among these valvular lesions pose important clinical implications for appropriate treatment for the underlying diseases. Prompt therapeutic measures in view of the underlying diseases of the valvular lesions are essential to prevent potential embolic events.

Antiplatelet Therapy in Stroke Prevention: Present and Future

White platelet-fibrin thrombi often form on roughened endothelial surfaces and unstable arterial plaques. Agents that reduce the tendency of platelets to aggregate, agglutinate, and secrete and to attach to endothelial surfaces have been explored as agents that prevent brain and heart infarction. Aspirin, ticlopidine, clopidogrel, dipyridamole, cilostazol, and glycoprotein llb/llla inhibitors are all used now and have various different modes of action and functions.

Antiphospholipid syndrome presenting as intracardiac thrombus with pulmonary embolism

The presence of antiphospholipid antibodies is associated with arterial and venous thrombosis. A young female with initial presentation of dyspnea and cough that lasted for days is reported. A computed tomographic scan of her chest and echocardiography showed features of thrombus formation over the right atrium, complicated with pulmonary thromboembolism. Antiphospholipid syndrome was diagnosed according to elevated activated partial thromboplastin time, high serum titers of anticardiolipin antibody, and the presence of intracardiac thrombus with pulmonary embolism. This thrombus was subsequently removed successfully with surgical intervention, and the patient's recovery was uneventful.

Transesophageal echocardiography and stroke

Only coronary artery disease and cancer kill more people than stroke in the United States. Transesophageal echocardiography (TEE) is a semi-invasive ultrasound cardiac imaging technique that provides superior anatomic detail as well as functional information. Searching for a cause of cerebral ischemia is the most common indication for TEE in cardiac ultrasound laboratories. Although TEE is not superior to transthoracic imaging for identifying all sources of cardiac embolism, its ability to more sensitively detect atrial septal aneurysm, patent foramen ovale, and aortic atheroma has been well described in recent years. Care must be exercised in using TEE to identify suspected cardiac sources of embolism, as potential etiologies described in the literature are not equally established by rigorous clinical trials. Confidence level in cause and effect for any cardiac pathology identified must be factored into therapeutic decisions.

Valve Morphology in Antiphospholipid Antibody Syndrome: Echocardiographic Features

Primary antiphospholipid antibody (PAP) syndrome can present with a variety of clinical manifestations including cardiac valvular lesions. Prior reports of the valvular lesions associated with PAP have been nonspecific. The purpose of this paper is to present four cases of patients with documented PAP and demonstrate the characteristic transesophageal echocardiographic features. The primary feature is focal, symmetrical, nodular thickening at the leaflet's coaptation points.

Surgical treatment of nonbacterial thrombotic endocarditis presenting with stroke

BACKGROUND

Necropsy studies have shown that nonbacterial thrombotic endocarditis (NBTE) may be associated with cerebral infarctions and antemortem diagnosis is now possible. However, the best treatment for patients with NBTE presenting with stroke is not known. We describe three patients presenting with an acute embolic stroke secondary to large,mobile vegetations detected by transthoracic (one case) or transesophageal echocardiography (two cases). All patients underwent surgery for removal of the vegetations to prevent recurrent embolic events; valve replacement was necessary in two cases. The sterile nature of the vegetations was confirmed by pathological examination and negative stains and cultures of the surgical samples. A previously unrecognized hypercoagulable condition was diagnosed in all patients (antiphospholipid antibody syndrome in two cases and disseminated adenocarcinoma in one case).

CONCLUSION

NBTE should be considered among the possible causes of embolic stroke even in the absence of history of cancer, hypercoagulability, or previous embolic manifestations. If NBTE is diagnosed, the possibility of underlying thrombophilia should be thoroughly investigated. Valvular surgery represents a valuable therapeutic alternative in patients with large mobile vegetations, valvular dysfunction or recurrent embolic events despite anticoagulation.

Assessment of cardiac structure and left atrial appendage functions in primary antiphospholipid syndrome: a transesophageal echocardiographic study

BACKGROUND AND PURPOSE

Although thromboembolic events are the major complication of primary antiphospholipid syndrome (PAPS), cardiac involvement is commonly present. Left atrial appendage (LAA) is recognized as an important source for thrombus formation and thromboembolism. The purpose of the study was to assess the structure and function of LAA with transesophageal echocardiography (TEE) in PAPS patients.

METHODS

Thirty-one PAPS patients (22 women, mean age 36+/-9 years) in sinus rhythm and 31 (17 women, mean age 37+/-7 years) controls with normal TEE examination were investigated.

RESULTS

Eighty-four percent of the PAPS patients had functional and structural valvular defect predominantly in the mitral valve. Valvular lesions were especially frequent in PAPS patients with a history of cerebrovascular events, patients with history of arterial thrombosis (91.6%), and patients with high titers of IgG anticardiolipin antibodies (100%). Intracardiac thrombus was present in 5 patients and in 1 of them it was located in LAA. The structure of LAA was similar between groups. Left atrial appendix ejection fraction (51.8+/-4 versus 48.6+/-5.5%; P<0.05) and LAA peak outflow velocity (87+/-10.9 versus 80.6+/-10.3 cm/s; P=0.02) was significantly higher in PAPS group compared with controls. In PAPS patients with mitral regurgitation (MR), LAA outflow peak velocity (84.3+/-10 versus 98.6+/-6.5 cm/s; P=0.002) and LAA inflow peak velocity (67.8+/-10.5 versus 80.8+/-8.6 cm/s; P=0.009) were significantly lower compared with PAPS patients without MR.

CONCLUSIONS

It was concluded that disease process in PAPS frequently involved cardiac valves especially mitral valve but spared LAA function. LAA function was normal, but intracardiac thrombus was present in 5 patients and 1 of them was located in LAA. MR in PAPS patients seems to impair LAA function.

Acute postoperative biventricular failure associated with antiphospholipid antibody syndrome

Antiphospholipid syndrome is probably the most common acquired hypercoagulable state, but information on perioperative management is sparse. Minor alterations in anticoagulant therapy, infection, or a surgical insult may trigger widespread thrombosis. The perioperative course of a 31-yr-old woman with primary anticardiolipin antiphospholipid antibody syndrome requiring a mitral valve replacement is described. Postoperatively, she developed acute global biventricular failure requiring extracorporeal membrane oxygenation support and plasmapheresis. The management of anticoagulation and cardiac surgery in this condition is reviewed.

Coronary and valvular syndromes and antiphospholipid antibodies

Since the recognition of the antiphospholipid syndrome (APS), a large number of cardiac manifestations have been reported in association with these antibodies, including coronary artery and valvular disease, cardiomyopathy, and intracardiac thrombosis. Most of these manifestations are explicable on the basis of thrombotic lesions either in the coronary circulation or on the valves and may mimic other similar conditions, such as rheumatic fever or infectious endocarditis. The APS coagulopathy in these patients requires the careful and judicious use of appropriate antiaggregant and anticoagulant therapy. In this review article, the focus will be on the main cardiac features related to the presence of antiphospholipid antibodies (aPLs), which may be of interest to clinicians.

Antiphospholipid antibodies and the risk of thromboembolic events in valvular heart disease

OBJECTIVE

To investigate the role of antiphospholipid antibodies (aPLs) in subsequent thromboembolic events and mortality in a prospective follow-up of 89 patients with severe, nonspecific valvular heart disease.

PATIENTS AND METHODS

Between November 1, 1993, and March 31, 1994, 89 patients with valvular heart disease were assessed for the presence of anticardiolipin antibodies and lupus anticoagulant. The primary end point was thromboembolic events, and the secondary end points were cardiovascular mortality and overall mortality.

RESULTS

All patients were followed up for a mean of 59 months; 1 patient (without aPLs) was lost to follow-up. Nineteen patients had increased titers of aPLs. Thromboembolic events were significantly more frequent in the aPL-positive group than in the aPL-negative group (7/19 [37%] vs 8/70 [11%]; P=.01). Cardiovascular mortality tended to be higher in the aPL-positive group than in the aPL-negative group (3 [16%] vs 6 [9%]; P = .40). However, in multivariate Cox analysis, presence of aPLs was not an independent risk factor for thromboembolic events.

CONCLUSION

Our results suggest that patients with severe valvular heart disease and aPLs have an increased risk for developing thromboembolic events.

Mitral valve thrombus mimicking a primary tumor in the antiphospholipid syndrome

Cardiac valvular abnormalities detected by echocardiography are relatively common in patients with the primary antiphospholipid syndrome. Valvular thickening with small vegetations are typical, but reports of lesion histology are rare. We report the case of a 50-year-old man presenting with thromboembolic phenomena who had a large (>2 cm), mobile, pedunculated, mass attached to the mitral valve that had the echocardiographic appearance of a primary valve tumor. Following surgical removal, histopathologic examination demonstrated pure fibrin thrombus and serological testing confirmed the antiphospholipid syndrome. This case highlights an unusual echocardiographic appearance of intracardiac thrombus in this syndrome.

Thrombus on the tricuspid valve in a patient with primary antiphospholipid syndrome after implantation of an inferior vena cave filter

A 62-year-old woman with a history of pulmonary embolism and primary antiphospholipid syndrome (PAPS) with positivity for lupus anticoagulant was admitted to hospital with shortness of breath. A filter had been implanted in her inferior vena cava (IVC) 5 years previously. Emergency echocardiography revealed a lobulated, mobile echogenic mass on the tricuspid valve, and on pulmonary perfusion scintigraphy several apparently new defects were noted. Fibrinolytic therapy improved her symptoms and the pulmonary perfusion, then intravenous heparinization was continued for a further week. Repeat echocardiography performed on the 7th day of the admission showed complete disappearance of the mass, which was retrospectively diagnosed as a thrombus based on its resolution with fibrinolytic and anticoagulant therapies.

Acute autoimmune cardiomyopathy in primary antiphospholipid antibody syndrome

We present a case of acute pulmonary oedema as the first presentation of autoimmune cardiomyopathy in primary antiphospholipid antibody syndrome in a patient who had no previous cardiac history. Five days of methylprednisolone at 500 mg/day followed by 100 mg/day for 10 days and then a weaning course of oral prednisone resulted in effective resolution of the acute diffuse cardiomyopathy. Her cardiac status became clinically and echocardiographically normal. We illustrate the effectiveness of immunosuppressive therapy as an adjunct to standard anti-failure measures in such presentations and we outline the association between antiphospholipid antibodies and cardiac dysfunction.

Hughes (antiphospholipid) syndrome. Clinical features

Hughes (antiphospholipid) syndrome is a noninflammatory autoimmune disease. The most critical pathologic process is thrombosis, which results in most of the clinical features suffered by these patients. Recurrent thrombosis together with an adverse pregnancy history and the presence of antiphospholipid antibodies defines the syndrome.

Evaluation of cardiac abnormalities and embolic sources in primary antiphospholipid syndrome by transesophageal echocardiography

OBJECTIVE

Valvular lesions are frequently present in Primary Antiphospholipid Syndrome (PAPS) patients using transthoracic and/or transesophageal echocardiography. The aim of this study was to describe the prevalence of cardiac abnormalities (valvular thickening and/or regurgitation) or potential embolic sources (spontaneous echocontrast and/or vegetations) in PAPS patients.

METHODS

Multiplane transesophageal echocardiography was performed consecutively on 40 PAPS PATIENTS: 17 of them with thrombocytopenia, 27 with at least one thromboembolic event (stroke, transient ischaemic attack, arterial and/or venous thrombosis, pulmonary embolism) and 14 with recurrent fetal loss.

DESIGN

Cardiac involvement (cardiac abnormalities and/or embolic sources) was present in 33/40 (82%) of PAPS patients. According to aCL titer these lesions were revealed in 17/24 (71%) of patients with aCL < or = 40 GPL-U, while these lesions were present in 100% of patients with aCL > 40 GPL-U. Three patients presented mitral stenosis and 3 non-infective valve masses or vegetations. Embolic sources were found in 4/24 (17%) patients with aCL < or = 40 GPL-U, while they were observed in 6/16 (37%) of patients with titer of aCL > 40 GPL-U (chi2 = 10.03, P < 0.01). Regression analysis showed a positive correlation between mitral valve thickening and aCL antibodies titer (r = 0.5; P < 0.001).

CONCLUSIONS

Valvular lesions are commonly found in PAPS patients. Our data showed a significant correlation among aCL titer, mitral leaflets thickening and thromboembolic events.

Right ventricular diastolic dysfunction in patients with anticardiolipin antibodies and antiphospholipid syndrome

OBJECTIVE

To evaluate the prevalence of diastolic dysfunction in patients with anticardiolipin antibodies (aCL) and to examine whether the antiphospholipid syndrome (APS) is associated with diastolic dysfunction independently of valvular abnormalities and systolic dysfunction.

METHODS

Pulsed, continuous, colour Doppler echocardiography was performed in 179 subjects, of whom 15 were excluded from the analysis because of systolic dysfunction or severe valvular disease. The remaining 164 subjects included 29 patients with primary APS, 26 patients with secondary APS (APS in the presence of systemic lupus erythematosus (SLE)), and 30 patients with SLE and aCL but without APS; 43 patients with SLE without aCL and 36 normal volunteers served as control groups.

RESULTS

The groups compared differed significantly in all measures of right ventricular function. There was a gradation of increasing diastolic function impairment as manifested by prolonged deceleration time (DT) and isovolumic relaxation time (IVRT) across the groups of patients with SLE without aCL, SLE with aCL, secondary APS, and primary APS. Differences in left ventricular diastolic function measures were less prominent. In regression analysis, DT increased by 19.6 ms (p=0.002) in the presence of primary APS and by 20.1 ms (p=0.038) in the presence of pulmonary hypertension. The titre of IgG aCL was the strongest predictor of a prolonged IVRT.

CONCLUSION

Diastolic dysfunction, in particular of the right ventricle-that is, independent of valvular disease and systolic dysfunction, is a prominent feature of APS and may be related to the pathogenesis of the syndrome.

Lipoprotein (a) and anticardiolipin antibodies are risk factors for clinically relevant restenosis after elective balloon percutaneous transluminal coronary angioplasty

Recent reports have shown the importance of new risk factors for cardiovascular disease. We investigated the relationship between Lp(a), fibrinolytic parameters and anticardiolipin antibodies (aCL) and the occurrence of clinical recurrence owing to restenosis after elective balloon percutaneous transluminal coronary angioplasty (PTCA) without stenting. In 167 patients, undergoing PTCA, Lp(a) plasma levels, aCL, euglobulin lysis time (ELT), plasminogen activator inhibitor-1 (PAI-1) activity and tissue-type plasminogen activator (t-PA) plasma levels were evaluated before the procedure. During follow-up 29 patients underwent clinical recurrence due to restenosis. Lp(a) levels were significantly higher in patients with restenosis in comparison to those without (P<0.05); an earlier restenosis was observed in patients with Lp(a) values >450 mg/L. Kaplan-Meier survival estimate showed an earlier occurrence of restenosis in patients with base-line Lp(a)>300 mg/l associated with aCL positivity. High Lp(a) plasma levels play a role in the occurrence of clinical recurrence due to restenosis after elective balloon PTCA without stenting; the association with aCL accelerates the development of restenosis.

Antiphospholipid syndrome and perioperative hemostatic management of cardiac valvular surgery

Hemostatic aspects of antiphospholipid syndrome (APS) present unique challenges to clinicians and laboratory personnel alike, particularly in the perioperative period. These challenges are especially evident in patients requiring cardiac valve replacement surgery. However, the literature outlining the optimal approach in such patients is limited. We present the case of a 25-year-old woman with severe aortic regurgitation as a result of APS with particular reference to the precautions necessary during perioperative care. Particularly important are the prevention of thrombotic or hemorrhagic complications, management of associated thrombocytopenia, and laboratory methods of perioperative anticoagulation monitoring in the setting of prolonged clotting times.

Echocardiography in nonbacterial thrombotic endocarditis: from autopsy to clinical entity

Bacteria-free verrucae, frequently termed "non-bacterial thrombotic endocarditis," have been recognized in autoimmune disorders as well as in neo-plastic diseases. The antemortem diagnosis of non-bacterial thrombotic endocarditis is rare, and most existing data result from postmortem examinations. In 3 prospective echocardiographic studies we found typical cardiac valvular lesions in patients with primary antiphospholipid syndrome, myelo-proliferative disorders, and solid malignant tumors. Cardiac lesions associated with these 3 different entities had common echocardiographic appearance and correlated positively with thromboembolic events. The possibility of common pathogenesis is suggested, and clinical significance is discussed.

Increased endothelial cell expression of alpha3beta1 integrin in cardiac valvulopathy in the primary (Hughes) and secondary antiphospholipid syndrome

The objective of this work was to determine markers of endothelial cell activation in valves from patients with antiphospholipid syndrome (APS) and heart valve involvement, in order to establish a role for endothelial cells in the pathogenesis of the valvular disease. Sixteen valves from ten patients with APS, obtained from autopsies or removed during valve replacement, were studied. Two groups of valves were used as controls. One group included seven normal valves from patients who died from non-cardiac diseases. The other group of valves were obtained from patients with bacterial endocarditis during autopsies or valve replacement operations. Immunoperoxidase and immunofluorescence stainings with antibodies to human immunoglobulins, endothelial cells, alpha3beta1 integrin, collagen IV, laminin and fibronectin were employed. Three histopathological patterns were apparent: normal valves, valves with verrucous endocarditis and valves with fibrocalcific changes. In all the valves with verrucous endocarditis the following findings were observed: (1) increased expression of the alpha3beta1 integrin on the endothelial cells, (2) increased amount of collagen IV, laminin and fibronectin, (3) proliferation of blood vessels and (4) linear subendothelial deposition of immunoglobulins and complement. The valves with fibrocalcific changes were deformed and showed a thick layer of collagen IV, laminin and fibronectin, yet in two valves the indothelial cells showed an expression of the alpha3beta1 integrin. The control valves did not express the integrin and had only a thin subendothelial band of collagen IV. In valves from patients with APS, 1 markers of endothelial cell activation are upregulated while the inflammatory exudate is scant. There is also a prominent deposition of immunoglobulins in the valves from patients with APS, suggesting a possible association between the deposition of the antibodies and the activation of the endothelial cells in APS.

Aortic valve replacement for aortic regurgitation in a patient with primary antiphospholipid syndrome

A 42-year-old woman with the diagnosis of aortic regurgitation was admitted to hospital for surgical treatment. Ten years ago, primary antiphospholipid syndrome had been diagnosed, and she had a history of recurrent spontaneous abortions and deep vein thrombosis. She was suffering from moderate exertional dyspnea and chest pain. Catheter investigation revealed progressive dilatation of the left ventricle and a deterioration of the ejection fraction. The aortic valve was excised and replaced with a mechanical valve. A specimen of the aortic valve showed localized thickening and shrinkage of the midportion and base of each cusp, with vegetation on the surface. These localized, specific findings suggest that another mechanism may be involved in the cardiac valve pathology in patients with primary antiphospholipid syndrome. No hemostatic or thromboembolic problems were encountered after the surgery, and her postoperative course was uneventful.

Echocardiographic evaluation of patients with primary antiphospholipid syndrome

BACKGROUND

A third to half of the patients with primary antiphospholipid syndrome have valve disease.

METHODS AND RESULTS

The echocardiographic characteristics of primary antiphospholipid syndrome were analyzed, and the utility of treatment with anticoagulants and/or antiplatelet agents (acetylsalicylic acid) is examined with the use of transesophageal echocardiography in the evaluation of valvular lesions after 1 year of therapy. Twenty-nine patients, 22 women and 7 men with average age of 35.4 years, were studied. Transesophageal echocardiography was performed on all patients before beginning anticoagulant and/or antiplatelet treatment. Valve lesions were found in 22 (75.9%) patients. Of these, other cardiac abnormalities were found in 3 cases, myocardial infarction in 2, and atrial septal defect in 1. In 7 (24.1%) cases, no valvular abnormality was detected, although in 1 of these, alterations in left ventricular segmental wall movement secondary to myocardial infarction were found. One year after initiation of anticoagulant and/or antiplatelet therapy, it was possible to perform transesophageal echocardiograms on 13 patients. No modification of valve lesions was found in 6 (46.2%) cases; new lesions had appeared in the remaining 7 (53.8%) as well as left ventricular apical akinesis in 1 case.

CONCLUSIONS

These results indicate that the predominant heart lesion in primary antiphospholipid syndrome is valvular; anticoagulant and/or antiplatelet treatment does not diminish the noninfective valve lesions, and on occasion this entity may be associated with myocardial infarction despite angiographically normal coronary arteries.

The presence of infection-related antiphospholipid antibodies in infective endocarditis determines a major risk factor for embolic events

OBJECTIVES

The impact of infection-associated antiphospholipid antibodies (APA) on endothelial cell activation, blood coagulation and fibrinolysis was evaluated in patients with infective endocarditis with and without major embolic events.

BACKGROUND

An embolic event is a common and severe complication of infective endocarditis. Despite the fact that APAs are known to be associated with infectious diseases, their pathogenic role in infective endocarditis has not been clearly defined.

METHODS

The relationship among the occurrence of major embolic events, echocardiographic vegetation size, endothelial cell activation, thrombin generation, fibrinolysis and APA was examined in 91 patients with definite infective endocarditis, including 26 patients with embolic events and 65 control subjects without embolic events.

RESULTS

Overall, 14.3% of patients exhibited elevated APA levels. Embolic events occurred more frequently in patients with elevated levels of APA than in patients without (61.5% vs. 23.1%; p = 0.008). Patients with elevated levels of APA showed higher levels of prothrombin-fragment F1 +2 (p = 0.005), plasminogen-activator inhibitor 1 (p = 0.0002), von Willebrand factor (p = 0.002) and lower levels of activated protein C (p = 0.001) than patients with normal levels of APA. Thrombin generation and endothelial cell activation were both positively correlated with levels of APA. The occurrence of elevated APA levels was frequently associated with structural valve abnormalities (p = 0.01) and vegetations >1.3 cm (p = 0.002).

CONCLUSIONS

Infection-associated elevated APA levels in patients with infective endocarditis are related to endothelial cell activation, thrombin generation and impairment of fibrinolysis. This may contribute to the increased risk for major embolic events in these patients.