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Alfatlawi H, Alharbi A, Shah M, Nawras Y, Altorok N. The impact of Libman-sacks endocarditis on inpatient outcomes with systemic lupus erythematosus: A retrospective study. Lupus 2024; 33:693-699. [PMID: 38564733 DOI: 10.1177/09612033241243179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
INTRODUCTION The existing literature offers limited insights into the influence of Libman-Sacks Endocarditis (LSE) on inpatient outcomes in individuals with Systemic Lupus Erythematosus (SLE). This study aimed to explore the characteristics and prognosis of SLE patients with LSE and the impact of LSE in patients with SLE on inpatient outcomes including inpatient mortality, length of stay, acute heart failure, atrial fibrillation, and cerebrovascular accidents (CVA). METHODS This study included adult patients who were hospitalized with SLE between the years 2019 and 2020, using the National Inpatient Sample (NIS) database. The total number of patients with a diagnosis of SLE in the years 2019 and 2020 in the NIS database was 150,411. Of those, 349 had a diagnosis of LSE. The study population was divided into two groups: one group with SLE and LSE, and another group with SLE but without LSE. RESULTS Caucasians made up 54.9% of the patients with a diagnosis of SLE in our patient population, while African Americans made up 26.9% and the Hispanics accounted for 12.2%. Of patients with LSE, Caucasians and African Americans represented 42.9% each. Patients with a diagnosis of LSE had a higher inpatient mortality than those with SLE without LSE (aOR: 9.74 CI 1.12-84.79, p 0.04). Patients with SLE with LSE were more likely to have acute heart failure than those without LSE, although this was not statistically significant (aOR 1.18 CI 0.13-11.07, p 0.88). Similarly, patients with SLE with LSE were more likely to have atrial fibrillation than those without LSE (aOR 4.45 CI: 0.77-25.57, p 0.10). CVAs were significantly higher in SLE patients with LSE than those without LSE (aOR 141.43 CI 16.59-1205.52, p < .01). DISCUSSION Patients who develop LSE were found to have significantly higher risks of inpatient mortality and cerebrovascular accidents. Early and precise detection of LSE in such patients may ensure timely intervention and prevention of the associated adverse outcomes. Further studies may attempt to develop screening methods for detection of LSE to effectively reduce morbidity and mortality associated with SLE.
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Affiliation(s)
- Halah Alfatlawi
- Department of Internal Medicine, The University of Toledo, Toledo, Ohio, USA
| | - Abdulmajeed Alharbi
- Department of Internal Medicine, The University of Toledo, Toledo, Ohio, USA
| | - Momin Shah
- Department of Internal Medicine, The University of Toledo, Toledo, Ohio, USA
| | - Yusuf Nawras
- The University of Toledo College of Medicine & Life Sciences, Toledo, Ohio, USA
| | - Nezam Altorok
- Department of Rheumatology, The University of Toledo, Toledo, Ohio, USA
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Roldan CA, Moazez C, Yatskowitz J, Maoz-Metzl D, Castlemain B, Fischer E. Cor Triatriatum Dexter and Right Atrial Mass Causing Severe Inflow Obstruction. CASE (PHILADELPHIA, PA.) 2024; 8:286-291. [PMID: 38765628 PMCID: PMC11096656 DOI: 10.1016/j.case.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
•CTD and SLE with APS-associated thrombogenesis can lead to RA thrombi formation. •In CTD, a large inferior RA chamber thrombi can cause severe inflow obstruction. •TTE and TEE are essential in defining the hemodynamic impact of CTD and RA thrombi. •TEE is key in guiding successful surgical resection of CTD and RA thrombi.
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Affiliation(s)
- Carlos A. Roldan
- Division of Cardiology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Carmel Moazez
- Division of Cardiology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Jerome Yatskowitz
- Division of Cardiology, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Daniel Maoz-Metzl
- Division of Cardiothoracic Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Brian Castlemain
- Division of Cardiothoracic Surgery, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Edgar Fischer
- Division of Pathology, University of New Mexico School of Medicine, Albuquerque, New Mexico
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Lu J, Bao S, Xu X, Jin Y, Liu C, Zhang Y, Wang Q, Jin Y. Libman-Sacks endocarditis in a child with systemic lupus erythematosus: a case report and literature review. Front Pediatr 2024; 12:1323943. [PMID: 38357507 PMCID: PMC10864555 DOI: 10.3389/fped.2024.1323943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/08/2024] [Indexed: 02/16/2024] Open
Abstract
Libman-Sacks endocarditis (LSE) is a cardiac condition characterized by the growth of verrucous vegetation. Although relatively rare in children, LSE is nevertheless a known cardiac manifestation of autoimmune diseases, including systemic lupus erythematosus (SLE). The mitral valve is the most commonly affected region, followed by the aortic valve, while the tricuspid and pulmonary valves are rarely affected. The management of established Libman-Sacks vegetation poses significant challenges, often necessitating surgical interventions, although surgery is not the primary treatment modality. Herein, we present the case of a 14-year-old Chinese female patient whose initial lupus manifestation included LSE, among other symptoms and signs that provided insights into the final diagnosis of SLE. After early comprehensive pharmacological treatment, tricuspid regurgitation and vegetation disappeared within 28 days without necessitating cardiac surgery, indicating that the resolution of LSE vegetation in this patient was achieved through a combination of immunosuppressive and anticoagulant therapy. These findings suggest the potential of this treatment approach as a viable model for the management of LSE in young patients.
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Affiliation(s)
- Jingyi Lu
- Department of Rheumatology and Immunology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shengfang Bao
- Department of Rheumatology and Immunology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xuemei Xu
- Department of Rheumatology and Immunology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yingying Jin
- Department of Rheumatology and Immunology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chenxi Liu
- Department of Rheumatology and Immunology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuqi Zhang
- Department of Pediatric Cardiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qian Wang
- Diagnostic Imaging Center, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yanliang Jin
- Department of Rheumatology and Immunology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Yazidi MA, Merzouk FZ, Rabii H, Benyoussef H, Bensahi I, Habbal R. Ischemic Stroke Revealing Libman-Sacks Endocarditis: A Case Report. J Saudi Heart Assoc 2023; 35:335-338. [PMID: 38116400 PMCID: PMC10727131 DOI: 10.37616/2212-5043.1360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 11/01/2023] [Accepted: 11/10/2023] [Indexed: 12/21/2023] Open
Abstract
Libman-Sacks endocarditis (LSE) is a characteristic but rare feature of systemic lupus erythematosus (SLE), which can be found in association with antiphospholipid syndrome (APS), exposing the patient to an increased embolism risk, particularly the occurrence of ischemic stroke. We present a case involving a 64-year-old man who was admitted for ischemic stroke accompanied by a fever. Cardiac investigation revealed mitral vegetations along with severe mitral regurgitation. The diagnosis of Libman-Sacks endocarditis associated with SLE and APS was made after a laboratory work-up showing negative blood cultures and positive antibodies. This case underlines the importance of early diagnosis for better management of this pathology.
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Affiliation(s)
- Malak A. Yazidi
- Cardiology Department of Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca,
Morocco
| | - Fatima Z. Merzouk
- Cardiology Department of Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca,
Morocco
| | - Hajar Rabii
- Cardiology Department of Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca,
Morocco
| | - Hicham Benyoussef
- Cardiovascular Surgery Department of Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca,
Morocco
| | - Ilham Bensahi
- Cardiology Department of Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca,
Morocco
| | - Rachida Habbal
- Cardiology Department of Cheikh Khalifa International University Hospital, Mohammed VI University of Health Sciences (UM6SS), Casablanca,
Morocco
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Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, Caselli S, Doenst T, Ederhy S, Erba PA, Foldager D, Fosbøl EL, Kovac J, Mestres CA, Miller OI, Miro JM, Pazdernik M, Pizzi MN, Quintana E, Rasmussen TB, Ristić AD, Rodés-Cabau J, Sionis A, Zühlke LJ, Borger MA. 2023 ESC Guidelines for the management of endocarditis. Eur Heart J 2023; 44:3948-4042. [PMID: 37622656 DOI: 10.1093/eurheartj/ehad193] [Citation(s) in RCA: 157] [Impact Index Per Article: 157.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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Parato VM, Belleggia S, Parato AG, Ianni U, Molisana M, Gizzi G, D'Agostino S, Dottori M, Di Eusanio M. Multi-valve Libman-Sacks's endocarditis-related multiple, massive and fatal systemic embolization. A case report and a review of diagnostic work-up. Monaldi Arch Chest Dis 2023. [PMID: 37817746 DOI: 10.4081/monaldi.2023.2729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 09/03/2023] [Indexed: 10/12/2023] Open
Abstract
We reported a case of non-bacterial thrombotic endocarditis (NBTE) in a 37-year-old woman who presented with signs and symptoms of cardio-embolic cerebral stroke caused by a prothrombotic state due to underlying advanced uterine cancer. Multimodal imaging, including 3D-ecocardiography, as well as laboratory and cultural tests, were critical in making the diagnosis. After starting anticoagulation therapy with low molecular weight heparin (LMWH), the patient underwent surgical aortic valve replacement due to worsening aortic valve function, initial left ventricle enlargement, increasing dimensions, and mobility of vegetations. Unfortunately, vegetations relapsed on the aortic valve bio-prosthesis as well as the mitral leaflets, resulting in a final picture of multi-valve NBTE. The fatal outcome was due to a massive multiple limb embolism, which resulted in leg amputations and septical complications. Starting with the case, we present a brief overview of the pathology's presentation, treatment, management, and prognosis, as well as the diagnostic work-up.
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Affiliation(s)
- Vito Maurizio Parato
- Cardiology and Rehabilitation Unit, Emergency Department, Madonna del Soccorso Hospital, San Benedetto del Tronto; Post-Graduation School of Cardiovascular Diseases, School of Medicine, Università Politecnica delle Marche, Ancona.
| | - Sara Belleggia
- Post-Graduation School of Cardiovascular Diseases, School of Medicine, Università Politecnica delle Marche, Ancona.
| | | | - Umberto Ianni
- Cardiology and Rehabilitation Unit, Emergency Department, Madonna del Soccorso Hospital, San Benedetto del Tronto.
| | - Michela Molisana
- Cardiology and Rehabilitation Unit, Emergency Department, Madonna del Soccorso Hospital, San Benedetto del Tronto.
| | - Germana Gizzi
- Cardiology and Rehabilitation Unit, Emergency Department, Madonna del Soccorso Hospital, San Benedetto del Tronto.
| | - Simone D'Agostino
- Cardiology and Rehabilitation Unit, Emergency Department, Madonna del Soccorso Hospital, San Benedetto del Tronto.
| | - Melissa Dottori
- Cardiology Unit and Echolab, Cardiovascular Sciences Department, University Hospital Lancisi-Salesi, Ancona.
| | - Marco Di Eusanio
- Cardiac Surgery Unit and Cardiovascular Sciences Department, University Hospital Lancisi-Salesi, Università Politecnica delle Marche, Ancona.
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Gorantla A, Schaible M, Sivakumar SS, Kishore A, Andrew-Palmer W, Unal S, Ramirez M, Panduranga V, Budzikowski AS. Embolic Phenomena of Libman-Sacks Endocarditis and Antiphospholipid Syndrome. Cureus 2023; 15:e46957. [PMID: 38021689 PMCID: PMC10640721 DOI: 10.7759/cureus.46957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Patients with systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APS) are at high risk of developing arterial or venous thromboembolism and a state of systemic hypercoagulability. Libman-Sacks endocarditis (LSE) is a type of non-bacterial endocarditis usually seen in patients with systemic lupus erythematosus and antiphospholipid antibody syndrome. These vegetations dislodge easily and can cause profound neurological and systemic complications in the form of emboli. We describe one such case of a young woman with known SLE who presented with an acute middle cerebral artery (MCA) stroke and was found to have APS with extensive mitral valve vegetation, indicating Libman-Sacks endocarditis on echocardiography. Recognizing the increasing frequency of both APS and LSE in patients with SLE and screening patients, especially the younger population with SLE, for APS is vital. Furthermore, in those patients presenting with embolic events, echocardiography plays a key role as it can help expedite the diagnosis of LSE. Our case report also reiterates that warfarin, when compared to direct oral anticoagulants (DOAC), is superior in decreasing future embolic events.
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Affiliation(s)
- Asher Gorantla
- Cardiology, State University of New York (SUNY) Downstate HSC, Brooklyn, USA
| | - Michael Schaible
- Internal Medicine, State University of New York Downstate Health Sciences University, Brooklyn, USA
| | - Shruthi S Sivakumar
- Neurology, State University of New York Downstate Health Sciences University, Brooklyn, USA
| | | | - Wayne Andrew-Palmer
- Internal Medicine, State University of New York Downstate Health Sciences University, Brooklyn, USA
| | - Selin Unal
- Internal Medicine, State University of New York Downstate Health Sciences University, Brooklyn, USA
| | - Michael Ramirez
- Internal Medicine, State University of New York Downstate Health Sciences University, Brooklyn, USA
| | - Varshitha Panduranga
- Internal Medicine, State University of New York Downstate Health Sciences University, Brooklyn, USA
| | - Adam S Budzikowski
- Division of Cardiovascular Medicine - Electrophysiology section, State University of New York Downstate Health Sciences University, Brooklyn, USA
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8
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Tran HY, Duong CL, Nguyen TH, Nguyen TV. Libman-Sacks endocarditis: regression after immunosuppressive and antiplatelet therapy in a patient with newly diagnosed systemic lupus erythematosus and positive antiphospholipid antibodies. BMJ Case Rep 2023; 16:e255726. [PMID: 37696608 PMCID: PMC10496658 DOI: 10.1136/bcr-2023-255726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Abstract
A woman in her 40s went to the hospital due to persistent headaches. On physical examination, a diastolic murmur in the third sternal intercostal space was the only finding. Echocardiograms were performed, revealing moderate aortic regurgitation and heterogeneously echoreflectant masses of variable shape with no independent mobility, mainly located on the ventricular side of the coaptation point of the three aortic cusps. Initially, aortic septic endocarditis was diagnosed, but no evidence of infection was found. Immunology blood tests were then performed, which determined the presence of systemic lupus erythematosus along with positive antiphospholipid antibodies. The diagnosis of Libman-Sacks endocarditis (LSEn) was established. After receiving steroids, hydroxychloroquine and aspirin, the aortic valvular lesions regressed significantly. This suggests that early treatment with anti-inflammatory and antithrombotic medications in the initial phase of LSEn may prevent the progression of valve deterioration.
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Affiliation(s)
- Hai Yen Tran
- Vietnam National Heart Institute - Bach Mai Hospital, Hanoi, Viet Nam
| | | | | | - Tuan Viet Nguyen
- Department of Cardiology, Thanh Hoa Province General Hospital, Thanh Hoa, Viet Nam
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Tonutti A, Scarfò I, La Canna G, Selmi C, De Santis M. Diagnostic Work-Up in Patients with Nonbacterial Thrombotic Endocarditis. J Clin Med 2023; 12:5819. [PMID: 37762758 PMCID: PMC10532023 DOI: 10.3390/jcm12185819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/23/2023] [Accepted: 09/05/2023] [Indexed: 09/29/2023] Open
Abstract
Nonbacterial thrombotic endocarditis (NBTE) is a form of endocarditis that occurs in patients with predisposing conditions, including malignancies, autoimmune diseases (particularly antiphospholipid antibody syndrome, which accounts for the majority of lupus-associated cases), and coagulation disturbances for which the correlation with classical determinants is unclear. The condition is commonly referred to as "marantic", "verrucous", or Libman-Sacks endocarditis, although these are not synonymous, representing clinical-pathological nuances. The clinical presentation of NBTE involves embolic events, while local valvular complications, generally regurgitation, are typically less frequent and milder compared to infective forms of endocarditis. In the past, the diagnosis of NBTE relied on post mortem examinations, while at present, the diagnosis is primarily based on echocardiography, with the priority of excluding infective endocarditis through comprehensive microbiological and serological tests. As in other forms of endocarditis, besides pathology, transesophageal echocardiography remains the diagnostic standard, while other imaging techniques hold promise as adjunctive tools for early diagnosis and differentiation from infective vegetations. These include cardiac MRI and 18FDG-PET/CT, which already represents a major diagnostic criterion of infective endocarditis in specific settings. We will herein provide a comprehensive review of the current knowledge on the clinics and therapeutics of NBTE, with a specific focus on the diagnostic tools.
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Affiliation(s)
- Antonio Tonutti
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (A.T.); (C.S.)
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Iside Scarfò
- Applied Diagnostic Echocardiography Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (I.S.); (G.L.C.)
| | - Giovanni La Canna
- Applied Diagnostic Echocardiography Unit, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy; (I.S.); (G.L.C.)
| | - Carlo Selmi
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (A.T.); (C.S.)
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
| | - Maria De Santis
- Department of Biomedical Sciences, Humanitas University, 20072 Pieve Emanuele, Italy; (A.T.); (C.S.)
- Rheumatology and Clinical Immunology, IRCCS Humanitas Research Hospital, 20089 Rozzano, Italy
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Wu BL, Hu Y, Luo XJ, Lei XL, Gan YQ, Zhu ZG, Yao HY, Zhang Y. Multiple organ dysfunction after mitral valve replacement in a patient with systemic lupus erythematosus complicated by Libman-Sacks endocarditis: a case report and literature review. J Int Med Res 2023; 51:3000605231198731. [PMID: 37702581 PMCID: PMC10501069 DOI: 10.1177/03000605231198731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/16/2023] [Indexed: 09/14/2023] Open
Abstract
This case report describes a 47-year-old woman with systemic lupus erythematosus (SLE) complicated by Libman-Sacks endocarditis (LSE) who developed multiple organ dysfunction after mitral valve replacement surgery. The patient presented with a 5-day history of cough, sputum, and fever. Transthoracic echocardiography showed significant vegetations on the mitral valve. Biopsy was performed, and the pathological diagnosis was SLE complicated by LSE. After the mitral valve replacement surgery, the patient developed clinical manifestations of hepatic and renal dysfunction, cardiopulmonary failure, oliguria, and shock. The clinical symptoms significantly improved after administration of mechanical ventilation, continuous renal replacement therapy, plasma exchange, anti-inflammatory and anti-infection treatments, immunomodulatory and immunosuppressive therapies, and low-molecular-weight heparin anticoagulation. Multiple organ dysfunction after mitral valve replacement in patients with SLE complicated by LSE has rarely been reported. This report discusses the clinical manifestations, pathogenesis, and treatment of this severe complication. We hope the sharing of our experience in this case will provide a clinical basis for the treatment of severe multiple organ dysfunction after mitral valve replacement in patients with SLE complicated by LSE.
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Affiliation(s)
- Bo Lan Wu
- Department of Gastroenterology, The Affiliated Nanhua Hospital, Hengyang, Hunan, China
- The Affiliated Nanhua Hospital, Hengyang Medical College, University of South China, Hengyang, Hunan, China
| | - Yang Hu
- Department of Gastroenterology, The Affiliated Nanhua Hospital, Hengyang, Hunan, China
- The Affiliated Nanhua Hospital, Hengyang Medical College, University of South China, Hengyang, Hunan, China
| | - Xiang Jun Luo
- Department of Rheumatology and Immunology, The Affiliated Nanhua Hospital, Hengyang, Hunan, China
| | - Xiang Li Lei
- Department of Rheumatology and Immunology, The Affiliated Nanhua Hospital, Hengyang, Hunan, China
| | - Yan Qing Gan
- Department of Intensive Care Unit, The Affiliated Nanhua Hospital, Hengyang, Hunan, China
| | - Zi Gui Zhu
- Department of Intensive Care Unit, The Affiliated Nanhua Hospital, Hengyang, Hunan, China
| | - Hong Yi Yao
- Department of Intensive Care Unit, The Affiliated Nanhua Hospital, Hengyang, Hunan, China
| | - Yi Zhang
- Department of Cardiothoracic Surgery, The Affiliated Nanhua Hospital, Hengyang, Hunan, China
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Asher Syed M, Khokhar MU, Akbar F, Asfand M, Shakoor H. Libman-Sacks Endocarditis With Triple Valvular Involvement. Cureus 2023; 15:e37734. [PMID: 37214052 PMCID: PMC10191869 DOI: 10.7759/cureus.37734] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2023] [Indexed: 05/23/2023] Open
Abstract
Systemic lupus erythematosus (SLE) is a systemic inflammatory autoimmune disease with a broad spectrum of clinical manifestations. Libman-Sacks endocarditis (LSE) is due to sterile vegetations that arise in association with SLE. Nonbacterial thrombotic endocarditis, also known as marantic endocarditis, Libman-Sacks endocarditis, and verrucous endocarditis, is linked to a number of illnesses, the most prevalent of which is advanced cancer. Most often, the surfaces of mitral and aortic valves are involved. However, the involvement of the tricuspid valve is possible and is rarely described in the literature. We present a case of a 25-year-old female who presented with LSE, lupus nephritis, and pulmonary involvement secondary to SLE. On detailed exploration, she was found to have SLE with lupus nephritis and pulmonary hypertension secondary to valvular involvement. Through this case, we would like to elaborate on the course of SLE with triple valvular involvement.
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Affiliation(s)
- Meeran Asher Syed
- Internal Medicine, Fauji Foundation Hospital Islamabad, Islamabad, PAK
| | | | - Farhan Akbar
- Internal Medicine, Fauji Foundation Hospital Rawalpindi, Rawalpindi, PAK
| | - Muhammad Asfand
- Internal Medicine, Fauji Foundation Hospital Islamabad, Islamabad, PAK
| | - Hassan Shakoor
- Internal Medicine, Fauji Foundation Hospital Islamabad, Islamabad, PAK
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Chalvon NB, Costedoat-Chalumeau N, Pennaforte JL, Servettaz A, Boulagnon Rombi C, Gavand PE, Lekieffre M, Le Guern V, Morel N, Cohen Aubart F, Haroche J, Mathian A, Collet JP, Piette JC, Amoura Z, Orquevaux P. Severe Libman-Sacks endocarditis complicating antiphospholipid syndrome: a retrospective analysis of 23 operated cases. Rheumatology (Oxford) 2023; 62:707-715. [PMID: 35686908 DOI: 10.1093/rheumatology/keac315] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 05/14/2022] [Accepted: 05/14/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Data on severe heart valve disease (HVD), including Libman-Sacks endocarditis, associated with SLE and/or APS requiring valvular surgery are scarce. We thus conducted a retrospective study, aimed at describing and clarifying clinical, laboratory, echocardiographic, histopathological and evolutional features of SLE and/or APS patients with severe associated-HVD. METHODS An observational retrospective multicentric analysis of 23 adults with SLE and/or APS and HVD between 1996 and 2019 and available histopathological report evaluating long-term follow-up. RESULTS Twenty-three individuals (20 females, median age 37 [range 17-76] years) were included. All had APS (thrombotic in 22, with an arterial phenotype in 15 and with catastrophic APS [CAPS] in six), and 11 (47%) had SLE. Systemic underlying disease had been diagnosed prior to HVD in 12 (52%). In 10 patients (43%), HVD was complicated by cerebral stroke prior to surgery. Twenty patients (87%) had only one pathological valve, the mitral valve in 18 patients (78%). Valvular thickening (n = 19) and valvular regurgitation (n = 19) were the most frequently reported lesions. Fifteen (62%) patients underwent mechanical valve replacement, six (26%) conservative valve repair (five were later re-operated after a median time of 1 [0-4] year), and two (9%) underwent biological valve replacement. Nine patients (39%) presented early-onset post-operative complications, including three CAPS immediately after surgery and one death. After surgery, 18 patients (78%) had normal postoperative valvular function, but almost half of the patients (43%) had post-operative neurological sequelae (median follow-up of 6 [2-20] years). CONCLUSION Severe HVD leading to surgery was strongly associated with thrombotic APS, especially arterial phenotypes. Half of the reported patients presented cerebral stroke complicating the HVD. Valvular surgery carried a significant risk of CAPS.
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Affiliation(s)
| | | | | | - Amelie Servettaz
- Department of Internal Medicine, University Hospital Center Reims, Reims
| | | | | | - Maud Lekieffre
- Department of Internal Medicine, Hospices Civils de Lyon (Lyon University Hospital Center), Lyon
| | | | | | | | | | | | | | | | | | - Pauline Orquevaux
- Department of Internal Medicine, Reims University Hospital, Reims, France
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Bui STT, Nguyen PH, Nguyen TN, Kirkpatrick JN, Nguyen VK, Nguyen HTT. Multivalvular involvement associated with Libman-Sacks endocarditis detected by multimodality imaging: A case report. Front Cardiovasc Med 2023; 10:1117711. [PMID: 37063968 PMCID: PMC10098003 DOI: 10.3389/fcvm.2023.1117711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/13/2023] [Indexed: 04/18/2023] Open
Abstract
Libman-Sacks endocarditis accounts for 6-11 percent of systemic lupus erythematosus patients and is associated with varying degrees of valvular dysfunction, increased risk for stroke and transient ischemic attacks, and increased mortality. In previous studies, left-sided valvular Libman-Sacks vegetations were more frequently detected than right sided vegetations; reported cases of bilateral involvement is very rare. A comprehensive clinical assessment and the multimodality imaging is of utmost importance in the management of systemic lupus erythematosus. In this case report, we describe a 31-year-old female patient with uncontrolled systemic lupus erythematosus initially presented with gastrointestinal symptoms but eventually had a vegetation-like structure on the posterior leaflet of the mitral valve which was revealed during routine echocardiography. Two-dimensional/three-dimensional transthoracic and transesophageal echocardiography, cardiac magnetic resonance, and cardiac computed tomography further characterized the mitral valve vegetation and revealed an additional vegetation of the pulmonary valve. Echocardiography remains the cornerstone for the detection of Libman-Sacks vegetations. Cardiac MRI and cardiac CT are useful in characterizing lesion size and effects and may prove particularly helpful in the assessment of right-sided or multivalvular endocarditis. The presence of focal brain lesions on brain MRI prompted antithrombotic therapy.
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Affiliation(s)
| | | | | | - James N. Kirkpatrick
- Cardiovascular Division, Department of Medicine, University of Washington Medical Center, Seattle, United States
| | | | - Hoai Thi Thu Nguyen
- Vietnam National Heart Institute, Bach Mai Hospital, Hanoi, Vietnam
- Department of Internal Medicine, VNU—University of Medicine and Pharmacy, Hanoi, Vietnam
- Correspondence: Hoai Thi Thu Nguyen
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14
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Álvarez Troncoso J, Soto Abanades C, Robles Marhuenda Á, Martínez Robles E, Noblejas Mozo A, Florez Gómez R, Pérez David E, Ríos Blanco JJ. Cardiac involvement in a Spanish unicentric prospective cohort of patients with systemic lupus erythematosus. Lupus 2023; 32:111-118. [PMID: 36415965 DOI: 10.1177/09612033221141264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Cardiac involvement is one of the most frequent manifestations of Systemic Lupus Erythematosus (SLE). Transthoracic echocardiogram (TTE) may be valuable for the early detection of cardiac abnormalities in SLE. Few studies analyze both TTE findings in SLE and the risk factors that predispose to different cardiac manifestations in a long follow-up cohort. We aimed to investigate cardiac involvement's prevalence, risk factors, and outcomes in a Spanish Lupus Clinic. METHODS Spanish single-center prospective study of cardiac involvement in SLE. Two hundred and one patients met the 2019 EULAR/ACR classification criteria, performed TTE, and were eligible for the study. RESULTS Cardiac involvement was present in 43.8%. Patients with older age, hypertension, hyperlipidemia, higher body mass index, peripheral arterial disease, thrombosis, and major cardiovascular events had significantly more cardiac involvement. Neurological, hematological, and serosal involvement (pleuritis and/or pericarditis) were clinical risk factors for abnormal TTE. The combination of the four clinical variables (dyspnea, chest pain, cough, and/or syncope) was present in 40.9% of the patients with abnormal TTE in the follow-up and was superior to each of the manifestations separately. Troponin I (TnI) ≥ 0.2 ng/mL and NTproBNP ≥ 300 pg/mL were excellent biomarkers with a good correlation with cardiac abnormalities. Anti-B2GP1 was the only autoantibody associated with cardiac involvement in our cohort. Presenting cardiac involvement was correlated with higher SLICC Damage Index and increased mortality risk in the 2-year follow-up period. CONCLUSIONS Cardiac involvement in SLE is diverse, heterogeneous, and highly prevalent. Presenting a pathological TTE was associated with greater damage accrual and greater mortality. Based on our results, we consider that echocardiographic screening of patients with SLE is essential, especially those symptomatic and/or with risk factors, to diagnose and treat cardiac involvement earlier.
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Affiliation(s)
- Jorge Álvarez Troncoso
- Servicio de Medicina Interna, Unidad de Enfermedades Autoinmunes Sistémicas, 16268Hospital Universitario La Paz, Madrid, Spain
| | - Clara Soto Abanades
- Servicio de Medicina Interna, Unidad de Enfermedades Autoinmunes Sistémicas, 16268Hospital Universitario La Paz, Madrid, Spain
| | - Ángel Robles Marhuenda
- Servicio de Medicina Interna, Unidad de Enfermedades Autoinmunes Sistémicas, 16268Hospital Universitario La Paz, Madrid, Spain
| | - Elena Martínez Robles
- Servicio de Medicina Interna, Unidad de Enfermedades Autoinmunes Sistémicas, 16268Hospital Universitario La Paz, Madrid, Spain
| | - Ana Noblejas Mozo
- Servicio de Medicina Interna, Unidad de Enfermedades Autoinmunes Sistémicas, 16268Hospital Universitario La Paz, Madrid, Spain
| | | | - Esther Pérez David
- Servicio de Cardiología, 16268Hospital Universitario La Paz, Madrid, Spain
| | - Juan José Ríos Blanco
- Servicio de Medicina Interna, Unidad de Enfermedades Autoinmunes Sistémicas, 16268Hospital Universitario La Paz, Madrid, Spain
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Restelli D, Trio O, Poleggi C, Piccione MC, Manganaro R, Certo G, Zito C, Andò G. Nonbacterial Thrombotic Endocarditis with Atypical Presentation as Overt Congestive Heart Failure. J Cardiovasc Echogr 2022; 32:225-228. [PMID: 36994120 PMCID: PMC10041397 DOI: 10.4103/jcecho.jcecho_42_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/25/2022] [Indexed: 03/31/2023] Open
Abstract
Nonbacterial thrombotic endocarditis (NBTE) is a form of endocarditis associated with malignancy or autoimmune disorders. Diagnosis remains a challenge as patients are often asymptomatic up to embolic events or rarely, valve dysfunction. We report a case of NBTE with uncommon clinical presentation and identified with multimodal echocardiography. An 82-year-old man presented to our outpatient clinic reporting dyspnea. Past medical history included hypertension, diabetes, kidney disease, and unprovoked deep-vein thrombosis. On physical examination, he was apyretic, mildly hypotensive, and hypoxemic, had a systolic murmur and lower limbs edema. Transthoracic echocardiography revealed severe mitral regurgitation due to verrucous thickening of the free margin of both leaflets, increased pulmonary pressure, and dilated inferior vena cava. Multiple blood cultures were negative. Transesophageal echocardiography confirmed "thrombotic" thickening of mitral leaflets. Nuclear investigations were highly suggestive of multi-metastatic pulmonary cancer. We did not further proceed with the diagnostic workup and prescribed palliative care. Lesions seen on echocardiography were suggestive of NBTE: they involved both sides of mitral leaflets, close to the edges, had irregular shape and echo density, a broad base, and no independent motion. Criteria for infective endocarditis were not met and the final diagnosis was paraneoplastic NBTE due to underlying lung cancer. We remark the lack of definitive recommendations about the treatment of NBTE and the only role of anticoagulation to prevent systemic embolism. We have reported a case of NBTE presenting with atypical symptoms and likely related to the prothrombotic state induced by underlying lung cancer. Provided the unconclusive microbiological tests, multimodal imaging has played a crucial role in the final diagnosis.
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Affiliation(s)
- Davide Restelli
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Azienda Ospedaliera Universitaria Policlinico “Gaetano Martino,” Messina, Italy
| | - Olimpia Trio
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Azienda Ospedaliera Universitaria Policlinico “Gaetano Martino,” Messina, Italy
| | - Cristina Poleggi
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Azienda Ospedaliera Universitaria Policlinico “Gaetano Martino,” Messina, Italy
| | - Maurizio Cusmà Piccione
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Azienda Ospedaliera Universitaria Policlinico “Gaetano Martino,” Messina, Italy
| | - Roberta Manganaro
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Azienda Ospedaliera Universitaria Policlinico “Gaetano Martino,” Messina, Italy
| | - Giuseppe Certo
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Azienda Ospedaliera Universitaria Policlinico “Gaetano Martino,” Messina, Italy
| | - Concetta Zito
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Azienda Ospedaliera Universitaria Policlinico “Gaetano Martino,” Messina, Italy
| | - Giuseppe Andò
- Department of Clinical and Experimental Medicine, Section of Cardiology, University of Messina, Azienda Ospedaliera Universitaria Policlinico “Gaetano Martino,” Messina, Italy
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Al Riyami H, Joshi N, Al Senaidi K, Al 'Abdul Salam N, Abdwani R. All Endocarditis Is Not Infective: Libman-Sacks Endocarditis. Cureus 2022; 14:e26526. [PMID: 35936150 PMCID: PMC9345777 DOI: 10.7759/cureus.26526] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2022] [Indexed: 11/05/2022] Open
Abstract
Libman-Sacks endocarditis (LSE) is an uncommon disorder that might be confused with infective endocarditis. It is one of the systemic lupus erythematosus (SLE) manifestations that could present with heart failure. We report a 12-year-old girl who presented with a history of shortness of breath, joint pain for four weeks, and fever for about one week. On examination, she was pale, edematous, and febrile. Her cardiac exam revealed a pan-systolic murmur of mitral regurgitation, harsh, grade 3/6 best heard at the apex. She was diagnosed with systemic lupus erythematosus with lupus nephritis and carditis. Her echocardiography revealed severe mitral regurgitation with nodular thickening of the valve in keeping with a diagnosis of LSE. After appropriate management of her underlying disorder using immunosuppressive, we saw a dramatic clinical improvement and her heart failure symptoms resolved. This case proves that SLE can have significant cardiac involvement and a proper evaluation would help in overall management and prognosis.
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17
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Choi E, Mathews LM, Paik J, Corretti MC, Wu KC, Michos ED, Hays AG, Mukherjee M. Multimodality Evaluation of Aortic Insufficiency and Aortitis in Rheumatologic Diseases. Front Cardiovasc Med 2022; 9:874242. [PMID: 35497991 PMCID: PMC9039512 DOI: 10.3389/fcvm.2022.874242] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/21/2022] [Indexed: 12/17/2022] Open
Abstract
Aortic insufficiency is commonly observed in rheumatologic diseases such as ankylosing spondylitis, systemic lupus erythematosus, antiphospholipid syndrome, Behçet's disease, granulomatosis with polyangiitis, and Takayasu arteritis. Aortic insufficiency with an underlying rheumatologic disease may be caused by a primary valve pathology (leaflet destruction, prolapse or restriction), annular dilatation due to associated aortitis or a combination of both. Early recognition of characteristic valve and aorta morphology on cardiac imaging has both diagnostic and prognostic importance. Currently, echocardiography remains the primary diagnostic tool for aortic insufficiency. Complementary use of computed tomography, cardiac magnetic resonance imaging and positron emission tomography in these systemic conditions may augment the assessment of underlying mechanism, disease severity and identification of relevant non-valvular/extracardiac pathology. We aim to review common rheumatologic diseases associated with aortic insufficiency and describe their imaging findings that have been reported in the literature.
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Affiliation(s)
- Eunjung Choi
- Dartmouth-Hitchcock Medical Center, Heart and Vascular Center, Lebanon, NH, United States
| | - Lena M. Mathews
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, United States
| | - Julie Paik
- Division of Rheumatology, Johns Hopkins University, Baltimore, MD, United States
| | - Mary C. Corretti
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, United States
| | - Katherine C. Wu
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, United States
| | - Erin D. Michos
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, United States
| | - Allison G. Hays
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, United States
| | - Monica Mukherjee
- Division of Cardiology, Johns Hopkins University, Baltimore, MD, United States
- *Correspondence: Monica Mukherjee
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18
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Chapa JJ, Ilonze OJ, Guglin ME, Rao RA. Heart transplantation in systemic lupus erythematosus: A case report and meta-analysis. Heart Lung 2022; 52:174-181. [DOI: 10.1016/j.hrtlng.2022.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 12/28/2021] [Accepted: 01/03/2022] [Indexed: 01/20/2023]
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Hussain K, Gauto-Mariotti E, Cattoni HM, Arif AW, Richardson C, Manadan A, Yadav N. A Meta-analysis and Systematic Review of Valvular Heart Disease in Systemic Lupus Erythematosus and Its Association With Antiphospholipid Antibodies. J Clin Rheumatol 2021; 27:e525-e532. [PMID: 32558678 DOI: 10.1097/rhu.0000000000001464] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Valvular heart disease (VHD) is a known cardiac manifestation of systematic lupus erythematosus (SLE). This systematic review aims to pool data from studies to estimate the frequency of valvular lesions in SLE patients. It also aims to demonstrate the association between VHD in SLE and antiphospholipid antibodies positivity. METHODS We included 27 studies after identifying relevant abstracts from PubMed, Scopus, and Google Scholar from the time of inception of database to 2019. Inclusion criteria consisted of English-language case-control and cohort studies. Three reviewers independently performed study selection, data extraction, and quality assessment using the Newcastle-Ottawa Scale for assessing risk for bias. RESULTS For VHD in SLE patients, the most commonly involved valve was the mitral valve, with 19.7% lesions being mitral regurgitation. In terms of morphological lesions, valve thickening (11.06%) and vegetations (11.76%) were among the most prevalent. Other commonly encountered lesions were mitral valve prolapse and tricuspid regurgitation in 9.25% and 10.86% of patients, respectively. A meta-analysis of 21 studies with 2163 SLE patients, of which 23.3% had valvular lesions, showed a significant association of anticardiolipin antibodies positivity with VHD (relative risk, 1.55; confidence interval, 1.10-2.18). CONCLUSIONS Systemic lupus erythematosus is associated with VHD, and it should be considered a clinical manifestation of SLE in the absence of other valvular pathologies. There is a clear association between VHD in SLE and immunoglobulin G anticardiolipin antibodies positivity. This association suggests that this subgroup of SLE patients might benefit from a screening echocardiogram.
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Affiliation(s)
- Kifah Hussain
- From the John H. Stroger Hospital of Cook County, Chicago
| | | | | | | | | | | | - Neha Yadav
- From the John H. Stroger Hospital of Cook County, Chicago
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20
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Ningyan W, Jappar IA, See Hooi E, Khung Keong Y. Severe mitral regurgitation from Libman-Sacks endocarditis treated with MitraClip: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab361. [PMID: 34661053 PMCID: PMC8517867 DOI: 10.1093/ehjcr/ytab361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 05/07/2021] [Accepted: 08/05/2021] [Indexed: 12/02/2022]
Abstract
Background Systemic lupus erythematosus (SLE) valvulopathy can manifest as a spectrum of pathologies and treatment of severe valvular dysfunction thus far has been surgical. However, surgery in patients with SLE is frequently associated with high morbidity and mortality due to the presence of significant co-morbidities. Case summary We report the case of a 41-year-old woman with SLE and anti-phospholipid syndrome with extensive co-morbidities including lupus nephritis, pancytopaenia, cerebrovascular accident, and severe airway obstruction from ipsilateral lung collapse and bronchiectasis. She had severe mitral regurgitation (MR) from Libman–Sacks endocarditis and in recent months developed heart failure with progressive exertional dyspnoea from New York Heart Association (NYHA) functional Class from New York Heart Association (NYHA) functional class II to III. In addition, there was progressive left ventricular dilatation and reduction in left ventricular ejection fraction. In view of the high surgical risk, she underwent transcatheter edge-to-edge repair (TEER) of the mitral valve with the MitraClip system. At 1-month follow-up, she was back to NYHA functional Class II with mild MR. Discussion Our case demonstrates that in select patient with suitable anatomy, TEER is a potential treatment option for severe MR from SLE valvulopathy.
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Affiliation(s)
- Wong Ningyan
- Department of Cardiology, National Heart Centre, 5 Hospital Drive, Singapore 169609, Singapore
| | - Ignasius Aditya Jappar
- Department of Cardiology, National Heart Centre, 5 Hospital Drive, Singapore 169609, Singapore
| | - Ewe See Hooi
- Department of Cardiology, National Heart Centre, 5 Hospital Drive, Singapore 169609, Singapore
| | - Yeo Khung Keong
- Department of Cardiology, National Heart Centre, 5 Hospital Drive, Singapore 169609, Singapore
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21
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Cohen A, Donal E, Delgado V, Pepi M, Tsang T, Gerber B, Soulat-Dufour L, Habib G, Lancellotti P, Evangelista A, Cujec B, Fine N, Andrade MJ, Sprynger M, Dweck M, Edvardsen T, Popescu BA. EACVI recommendations on cardiovascular imaging for the detection of embolic sources: endorsed by the Canadian Society of Echocardiography. Eur Heart J Cardiovasc Imaging 2021; 22:e24-e57. [PMID: 33709114 DOI: 10.1093/ehjci/jeab008] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/07/2021] [Indexed: 12/28/2022] Open
Abstract
Cardioaortic embolism to the brain accounts for approximately 15-30% of ischaemic strokes and is often referred to as 'cardioembolic stroke'. One-quarter of patients have more than one cardiac source of embolism and 15% have significant cerebrovascular atherosclerosis. After a careful work-up, up to 30% of ischaemic strokes remain 'cryptogenic', recently redefined as 'embolic strokes of undetermined source'. The diagnosis of cardioembolic stroke remains difficult because a potential cardiac source of embolism does not establish the stroke mechanism. The role of cardiac imaging-transthoracic echocardiography (TTE), transoesophageal echocardiography (TOE), cardiac computed tomography (CT), and magnetic resonance imaging (MRI)-in the diagnosis of potential cardiac sources of embolism, and for therapeutic guidance, is reviewed in these recommendations. Contrast TTE/TOE is highly accurate for detecting left atrial appendage thrombosis in patients with atrial fibrillation, valvular and prosthesis vegetations and thrombosis, aortic arch atheroma, patent foramen ovale, atrial septal defect, and intracardiac tumours. Both CT and MRI are highly accurate for detecting cavity thrombosis, intracardiac tumours, and valvular prosthesis thrombosis. Thus, CT and cardiac magnetic resonance should be considered in addition to TTE and TOE in the detection of a cardiac source of embolism. We propose a diagnostic algorithm where vascular imaging and contrast TTE/TOE are considered the first-line tool in the search for a cardiac source of embolism. CT and MRI are considered as alternative and complementary tools, and their indications are described on a case-by-case approach.
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Affiliation(s)
- Ariel Cohen
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI - UMR 1099, F-35000 Rennes, France
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCS, Via Parea 4, 20141, Milan, Italy
| | - Teresa Tsang
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bernhard Gerber
- Service de Cardiologie, Département Cardiovasculaire, Cliniques Universitaires St. Luc, Division CARD, Institut de Recherche Expérimental et Clinique (IREC), UCLouvainAv Hippocrate 10/2803, B-1200 Brussels, Belgium
| | - Laurie Soulat-Dufour
- Assistance Publique-Hôpitaux de Paris, Saint-Antoine and Tenon Hospitals, Department of Cardiology, and Sorbonne University, Paris, France.,INSERM unit UMRS-ICAN 1166; Sorbonne-Université, Paris, France
| | - Gilbert Habib
- Aix Marseille Univ, IRD, MEPHI, IHU-Méditerranée Infection, APHM, La Timone Hospital, Cardiology Department, Marseille, France
| | - Patrizio Lancellotti
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, CHU SartTilman, Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Arturo Evangelista
- Servei de Cardiologia. Hospital Universitari Vall d'Hebron-VHIR. CIBER-CV. Pº Vall d'Hebron 119. 08035. Barcelona. Spain
| | - Bibiana Cujec
- Division of Cardiology, University of Alberta, 2C2.50 Walter Mackenzie Health Sciences Center, 8440 112 St NW, Edmonton, Alberta, Canada T6G 2B7
| | - Nowell Fine
- University of Calgary, Libin Cardiovascular Institute, South Health Campus, 4448 Front Street Southeast, Calgary, Alberta T3M 1M4, Canada
| | - Maria Joao Andrade
- Maria Joao Andrade Cardiology Department, Hospital de Santa Cruz-Centro Hospitalar Lisboa Ocidental, Av. Prof. Dr. Reinaldo dos Santos 2790-134 Carnaxide, Portugal
| | - Muriel Sprynger
- Department of Cardiology-Angiology, University Hospital Liège, Liège, Belgium
| | - Marc Dweck
- British Heart Foundation, Centre for Cardiovascular Science, Edinburgh and Edinburgh Imaging Facility QMRI, University of Edinburgh, United Kingdom
| | - Thor Edvardsen
- Faculty of medicine, Oslo University, Oslo, Norway and Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Bogdan A Popescu
- Cardiology Department, University of Medicine and Pharmacy 'Carol Davila', Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C. C. Iliescu', Sos. Fundeni 258, sector 2, 022328 Bucharest, Romania
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Assan F, de Zuttere D, Bottin L, Tavolaro S, Courvoisier DS, Barbaud A, Alamowitch S, Francès C, Chasset F. Echocardiographic features in antiphospholipid-negative Sneddon's syndrome and potential association with severity of neurological symptoms or recurrence of strokes: a longitudinal cohort study. Eur Heart J Cardiovasc Imaging 2021; 22:119-128. [PMID: 31898726 DOI: 10.1093/ehjci/jez312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 10/19/2019] [Accepted: 12/07/2019] [Indexed: 12/18/2022] Open
Abstract
AIMS Sneddon's syndrome (SS) may be classified as antiphospholipid positive (aPL+) or negative (aPL- SS). An association between Libman-Sacks (LS) endocarditis and strokes has been described in aPL+ patients. To describe cardiac involvement in aPL- SS and assess the potential association between LS endocarditis and severity or recurrence of neurological symptoms. METHODS AND RESULTS This longitudinal cohort study included aPL- SS patients followed in our departments between 1991 and June 2018. All patients underwent transthoracic 2D and Doppler echocardiography at diagnosis. Follow-up echocardiography was performed annually and the potential relationship between LS endocarditis development and neurovascular relapse as well as long-term cardiac worsening was prospectively assessed. We included 61 patients [52 women; median age 45 (range 24-60)]. For valvular involvement, 36 (59%) patients showed leaflet thickening; 18 (29.5%) had LS endocarditis at baseline. During a median follow-up of 72 months, LS endocarditis developed in eight (17.4%) patients, and 13 (28.3%) showed significant worsening of their cardiac status, including two who needed valvular replacement. After adjusting for baseline antithrombotic treatment regimen, neither the presence of LS endocarditis at baseline nor development during follow-up was associated with neurological relapse [hazard ratio (HR): 1.06, 95% confidence interval (CI): 0.33-4.74, P = 0.92] and [HR: 0.38, 95% CI: 0.02-1.89, P = 0.31], respectively. CONCLUSION A long-term follow-up is needed to detect cardiac complications in aPL- SS. No change in neurological relapse was observed in patients presenting LS endocarditis occurrence during follow-up without any modification in antithrombotic treatment. Further research is necessary to assess the usefulness of treatment escalation in these patients.
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Affiliation(s)
- Florence Assan
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Dermatology and Allergology Department, Hôpital Tenon, 4 rue de la Chine 75020 Paris, France
| | - Dominique de Zuttere
- Functional exploration Department, Hôpital Francp-Brittanique, 4 rue Kléber 92300 Levallois-Perret, France
| | - Laure Bottin
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Neurology Department, Hôpital Saint Antoine, 184 rue du Faubourg Saint-Antoine 75012 Paris, France
| | - Sebastian Tavolaro
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Radiology Department, Hôpital Tenon, 4 rue de la Chine 75020 Paris, France
| | - Delphine S Courvoisier
- Division of rheumatology, Department of Medicine, University of Geneva, 1205 Geneva, Switzerland
| | - Annick Barbaud
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Dermatology and Allergology Department, Hôpital Tenon, 4 rue de la Chine 75020 Paris, France
| | - Sonia Alamowitch
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Neurology Department, Hôpital Saint Antoine, 184 rue du Faubourg Saint-Antoine 75012 Paris, France
| | - Camille Francès
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Dermatology and Allergology Department, Hôpital Tenon, 4 rue de la Chine 75020 Paris, France
| | - François Chasset
- Sorbonne Université, Faculté de Médecine Sorbonne Université, APHP Dermatology and Allergology Department, Hôpital Tenon, 4 rue de la Chine 75020 Paris, France
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23
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Roldan CA, Sibbitt WL, Greene ER, Qualls CR, Jung RE. Libman-Sacks endocarditis and associated cerebrovascular disease: The role of medical therapy. PLoS One 2021; 16:e0247052. [PMID: 33592060 PMCID: PMC7886205 DOI: 10.1371/journal.pone.0247052] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Accepted: 01/31/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Libman-Sacks endocarditis in patients with systemic lupus erythematosus (SLE) is commonly complicated with embolic cerebrovascular disease (CVD) or valve dysfunction for which high-risk valve surgery is frequently performed. However, the role of medical therapy alone for Libman-Sacks endocarditis and associated acute CVD remains undefined. OBJECTIVE To determine in this cross-sectional and longitudinal study if conventional anti-inflammatory and anti-thrombotic therapy may be an effective therapy in SLE patients with Libman-Sacks endocarditis and associated acute CVD. METHODS AND MATERIALS 17 SLE patients with Libman-Sacks endocarditis detected by two-and-three-dimensional transesophageal echocardiography (TEE) and complicated with acute CVD [stroke/TIA, focal brain injury on MRI, or cognitive dysfunction] were treated with conventional anti-inflammatory and anti-thrombotic therapy for a median of 6 months and then underwent repeat TEE, transcranial Doppler, brain MRI, and neurocognitive testing for re-assessment of Libman-Sacks endocarditis and CVD. RESULTS Valve vegetations decreased in number, diameter, and area (all p ≤0.01); associated valve regurgitation significantly improved (p = 0.04), and valve thickening did not progress (p = 0.56). In 13 (76%) patients, valve vegetations or valve regurgitation resolved or improved in number and size or by ≥1 degree, respectively, as compared to 4 (24%) patients in whom vegetations or valve regurgitation persisted unchanged or increased in size or by ≥1 degree (p = 0.03). Also, cerebromicroembolism, lobar and global gray and white matter cerebral perfusion, ischemic brain lesion load, and neurocognitive dysfunction resolved or significantly improved (all p ≤0.04). CONCLUSION These preliminary data suggest that combined conventional anti-inflammatory and antithrombotic therapy may be an effective treatment for Libman-Sacks endocarditis and its associated CVD and may obviate the need for high-risk valve surgery.
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Affiliation(s)
- Carlos A Roldan
- Department of Medicine, Divisions of Cardiology and Rheumatology, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Wilmer L Sibbitt
- Department of Medicine, Divisions of Cardiology and Rheumatology, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Ernest R Greene
- Department of Medicine, Divisions of Cardiology and Rheumatology, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Clifford R Qualls
- Department of Medicine, Divisions of Cardiology and Rheumatology, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Rex E Jung
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
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Ye T, Wang J, Liao S. Mitral Valve Repair for Isolated Libman-Sacks Endocarditis in a Patient with Primary Antiphospholipid Syndrome. Int Heart J 2021; 62:181-185. [PMID: 33518657 DOI: 10.1536/ihj.20-260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Libman-Sacks endocarditis, characterized by verrucous vegetations formation, is a typical cardiac manifestation of autoimmune diseases such as systemic lupus erythematosus (SLE) and antiphospholipid syndrome (APS). Although typically mild and asymptomatic, Libman-Sacks endocarditis can lead to serious complications, including thromboembolic events, superimposed bacterial endocarditis, and severe valvular regurgitation and/or stenosis, and valve surgery may be required. Here, we report a case of mitral valve repair for a large Libman-Sacks vegetation in a 29-year-old woman with a history of APS with cerebral infarction. Transesophageal echocardiography (TEE) demonstrated an isolated large mobile vegetation on the atrial side of posterior mitral valve leaflet, with severe mitral regurgitation. Next, we organized a multidisciplinary team meeting to better evaluate the case before performing the surgery. To prevent further thromboembolic events, and due to the insufficiency of the mitral valve, the patient was accepted for mitral valve surgery, and she was discharged uneventfully 10 days after successful surgery. She was managed with long-term anticoagulation medicine after surgery and followed up for 2 years with no complications. The present case showed mitral repair is feasible and effective in young female patients of child-bearing age, and the lesion only localized mitral valve abnormalities caused by Libman-Sacks endocarditis.
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Affiliation(s)
- Teng Ye
- Department of Ultrasound, The First Affiliated Hospital of Wenzhou Medical University
| | - Jue Wang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Wenzhou Medical University
| | - Shusheng Liao
- Department of Ultrasound, The First Affiliated Hospital of Wenzhou Medical University
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25
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Garcia-Diaz J, Escudero-Salamanca M, Alvarez-Santana R, Espinola-Zavaleta N. Catastrophic antiphospholipid syndrome associated with systemic lupus erythematosus: a case-based review. Future Cardiol 2020; 17:985-990. [PMID: 33140653 DOI: 10.2217/fca-2020-0145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Antiphospholipid syndrome (APS) can occur as a primary disease or secondary to an underlying disease, such as systemic lupus erythematosus, or other systemic autoimmune diseases. Catastrophic APS refers to a rapid progression of the disease with the development of thrombotic events that affect three or more organs. This is the case of a 22-year-old woman without history of pregnancy. She developed a catastrophic APS associated with systemic lupus erythematosus, with kidney damage (focal lupus nephritis III), pulmonary embolism, and Libman-Sacks mitral valve endocarditis. Accurate diagnosis and optimal medical treatment (anticoagulants, corticosteroids, antimalarials, diuretics) improved her disease, and the patient was discharged in good clinical condition and continues her multidisciplinary follow-up in the outpatient clinic of our institution.
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Affiliation(s)
- Jesus Garcia-Diaz
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | - Mara Escudero-Salamanca
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | - Ricardo Alvarez-Santana
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico
| | - Nilda Espinola-Zavaleta
- Department of Nuclear Cardiology, National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico.,Department of Echocardiography, ABC Medical Center, Mexico City, Mexico
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26
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Allain JS, Paven E, Henriot B, Belhomme N, Le Bot A, Ballerie A, Jego P. [Libman-Sacks endocarditis under apixaban in a patient with a high-risk profile venous antiphospholipid syndrome]. Rev Med Interne 2020; 42:218-222. [PMID: 33153775 DOI: 10.1016/j.revmed.2020.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/23/2020] [Accepted: 08/03/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Libman-Sacks endocarditis is a rare complication of antiphospholipid syndrome. Anti-vitamin K therapy is the standard treatment, although valvular replacement surgery may be required in some severe cases. In the latest EULAR recommendations, it is advised not to use direct oral anticoagulants in the management of antiphospholipid syndrome, especially of high-risk profile. CASE REPORT We present a case of a mitral Libman-Sacks endocarditis complicated with multiple strokes occurring in the setting of an antiphospholipid syndrome with triple positive antibody profile in a 63-year-old woman with multiple sclerosis. She was previously treated with apixaban for two years. Tinzaparin followed by prolonged warfarine treatment and two months of hydroxychloroquine resulted in valvular improvement. CONCLUSION To our knowledge, this is the first case of Libman-Sacks endocarditis occurring during apixaban therapy in a patient with antiphospholipid syndrome. This severe case highlights the inefficiency of direct oral anticoagulants to prevent thrombotic events in the antiphospholipid syndrome.
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Affiliation(s)
- J-S Allain
- Department of Internal Medicine and Clinical Immunology, Unité d'Investigation Clinique, Rennes University Hospital, Pontchaillou Hospital, 2, rue Henri-Le-Guilloux, 35 000 Rennes, France; Pole CVM, Paul Broussais General Hospital Center, Saint Malo, France; Clinical Investigation Center of Rennes, National Institute of Health and Scientific Research (CIC-INSERM 1414), Rennes, France.
| | - E Paven
- Department of Cardiology, Rennes University Hospital, Pontchaillou Hospital, Rennes, France
| | - B Henriot
- Pole CVM, Paul Broussais General Hospital Center, Saint Malo, France
| | - N Belhomme
- Department of Internal Medicine and Clinical Immunology, Unité d'Investigation Clinique, Rennes University Hospital, Pontchaillou Hospital, 2, rue Henri-Le-Guilloux, 35 000 Rennes, France
| | - A Le Bot
- Infectious Diseases and Intensive Care Unit, Rennes University Hospital, Pontchaillou Hospital, Rennes, France
| | - A Ballerie
- Department of Internal Medicine and Clinical Immunology, Unité d'Investigation Clinique, Rennes University Hospital, Pontchaillou Hospital, 2, rue Henri-Le-Guilloux, 35 000 Rennes, France; Inserm, EHESP, IRSET (institut de recherche en santé, Environnement et travail)-UMR_S 1085, Rennes 1 University, Rennes, France
| | - P Jego
- Department of Internal Medicine and Clinical Immunology, Unité d'Investigation Clinique, Rennes University Hospital, Pontchaillou Hospital, 2, rue Henri-Le-Guilloux, 35 000 Rennes, France; Inserm, EHESP, IRSET (institut de recherche en santé, Environnement et travail)-UMR_S 1085, Rennes 1 University, Rennes, France
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Kato T, Takama N, Harada T, Koitabashi N, Murakami M, Abe T, Kurabayashi M. Nonbacterial Thrombotic Endocarditis-A Rare Case of Acute Libman-Sacks Endocarditis Complicated by Multiple Cerebral Infarcts: Case Report and Literature Review. ACTA ACUST UNITED AC 2020; 4:507-511. [PMID: 33376843 PMCID: PMC7756186 DOI: 10.1016/j.case.2020.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Acute NBTE can be diagnosed on TTE and TEE. LSE complicated by multiple coagulopathies may trigger NBTE and cerebral infarcts. Screening with TTE is essential in patients with SLE with multiple risk factors.
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Affiliation(s)
- Toshimitsu Kato
- Department of Clinical Laboratory, Gunma University Hospital, Maebashi, Gunma, Japan
| | - Noriaki Takama
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Tomonari Harada
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Norimichi Koitabashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Masami Murakami
- Department of Clinical Laboratory, Gunma University Hospital, Maebashi, Gunma, Japan
| | - Tomonobu Abe
- Department of Cardiovascular Surgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Masahiko Kurabayashi
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Mizrahi M, Jimenez-Becerra S, Rivera-Navarrete E, Gomez-Sanchez M. Severe mitral valve regurgitation secondary to Libman-Sacks endocarditis. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2020; 10:382-385. [PMID: 33224587 PMCID: PMC7675162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 08/28/2020] [Indexed: 06/11/2023]
Abstract
Although uncommon, Libman-Sack endocarditis is the most characteristic cardiac manifestation of Systemic Lupus Erythematosus (SLE). It forms vegetations made of inflammatory tissue on the cardiac valves, leading them to malfunction. Here we present a case of a young woman who presented with severe mitral valve regurgitation in need for a valve replacement. Integral evaluation of the patient revealed the diagnosis of SLE, which was aggressively treated in an outpatient setting with immunosuppressive therapy. Only after achieving medical stabilization of the underlying disease, she was able to undergo surgical mitral valve replacement. After the surgery, the patient no longer suffered from mitral regurgitation, and with a mechanical prosthesis in place, the risk of Libman-Sacks endocarditis recurrence is thought to be minimal.
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Affiliation(s)
- Michelle Mizrahi
- General Physician, National Institute of Cardiology “Ignacio Chavez”Juan Badiano 1, 5to piso, Col. Seccion XVI, Tlalpan, CP 14080 Mexico City, Mexico
| | - Silvia Jimenez-Becerra
- Attending Pathologist, National Institute of Cardiology “Ignacio Chavez”Juan Badiano 1, 5to piso, Col. Seccion XVI, Tlalpan, CP 14080 Mexico City, Mexico
| | - Eric Rivera-Navarrete
- Cardiac Surgery Resident, National Institute of Cardiology “Ignacio Chavez”Juan Badiano 1, 5to piso, Col. Seccion XVI, Tlalpan, CP 14080 Mexico City, Mexico
| | - Mario Gomez-Sanchez
- Attending Cardiovascular Surgeon, National Institute of Cardiology “Ignacio Chavez”Juan Badiano 1, 5to piso, Col. Seccion XVI, Tlalpan, CP 14080 Mexico City, Mexico
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Lampert J, Halista M, Pujadas E, Alexander S, Bier B, Hadley M, Healy M, Yunus F, Goldman M, Fuster V. Cardiogenic Shock and Mitral Valve Chord Rupture: A Rare Presentation of Libman-Sacks Endocarditis. JACC Case Rep 2020; 2:1988-1991. [PMID: 34317095 PMCID: PMC8299131 DOI: 10.1016/j.jaccas.2020.06.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 06/08/2020] [Accepted: 06/24/2020] [Indexed: 11/14/2022]
Abstract
Distinguishing Libman-Sacks endocarditis from other valvular heart disease etiologies has important implications for management. We present a case of a 23-year-old man who presented in extremis with fever and cardiogenic shock caused by Libman-Sacks endocarditis with associated mitral valve chord rupture. (Level of Difficulty: Beginner.)
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Affiliation(s)
| | - Michael Halista
- Icahn School of Medicine at Mount Sinai, Department of Internal Medicine, New York, New York
| | - Elisabet Pujadas
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, New York
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30
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Premyodhin N, Glovaci D, Azam S, Chou R, Barseghian A. Distinguishing aortic valve thrombus from Libman-Sacks endocarditis in antiphospholipid syndrome: imaging and management. Future Cardiol 2020; 17:101-111. [PMID: 32648500 DOI: 10.2217/fca-2020-0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aortic valve (AV) thrombus, a rare complication of antiphospholipid syndrome (APLS), is important to distinguish from Libman-Sacks endocarditis because of its responsiveness to anticoagulation. This may be attributed to immunopathologic differences underpinning their development. We present the case of a 45-year-old woman with high-risk primary APLS who developed an AV mass and was taken for valvular repair surgery but found to have pure thrombus and normal valve leaflets. In such cases, a trial of conservative management with anticoagulation may be adequate. Echocardiography, computed tomography and MRI findings suggestive of thrombus without endocarditis are presented. A literature review of histopathologic, imaging and treatment implications of pure AV thrombus in the context of APLS is included.
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Affiliation(s)
- Ned Premyodhin
- Department of Medicine, Division of Cardiology, University of California, Irvine School of Medicine, 333 City Boulevard West, Suite 400, Orange, CA 92868, USA
| | - Diana Glovaci
- Department of Medicine, Division of Cardiology, University of California, Irvine School of Medicine, 333 City Boulevard West, Suite 400, Orange, CA 92868, USA
| | - Sarah Azam
- Department of Medicine, Division of Cardiology, University of California, Irvine School of Medicine, 333 City Boulevard West, Suite 400, Orange, CA 92868, USA
| | - Raymond Chou
- Department of Surgery, Division of Cardiothoracic Surgery, University of California, Irvine School of Medicine, 101 The City Drive South, Building Number 53, Room Number 117, Orange, CA 92868, USA
| | - Ailin Barseghian
- Department of Medicine, Division of Cardiology, University of California, Irvine School of Medicine, 333 City Boulevard West, Suite 400, Orange, CA 92868, USA
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Mohammadi Kebar Y, Avesta L, Habibzadeh A, Hemmati M. Libman-Sacks endocarditis in patients with systemic lupus erythematosus with secondary antiphospholipid syndrome. CASPIAN JOURNAL OF INTERNAL MEDICINE 2019; 10:339-342. [PMID: 31558998 PMCID: PMC6729157 DOI: 10.22088/cjim.10.3.339] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background: Libman-Sacks endocarditis (LSE) is characterized by sterile lesions that commonly affect the aortic and mitral heart valves. Antiphospholipid syndrome (APS) and systemic lupus erythematosus (SLE) have been associated with LSE. Cardiac manifestations including LSE could be interrelated with other manifestations and early diagnosis could help in preventing further complications. Case presentation: Here, we report three cases of LSE in SLE patients with secondary APS. All patients presented with neurological manifestations and LSE was diagnosed by Transesophageal echocardiography (TEE). All three patients were treated for the underlying disease and also received anticoagulant therapy. Conclusion: In all patients with SLE and secondary APS, LSE should be considered if a patient manifests any evidence of neurologic involvement.
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Affiliation(s)
| | - Leili Avesta
- Department of Cardiology, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Afshin Habibzadeh
- Department of Internal Medicine, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Mehdi Hemmati
- Department of Medicine, Medstar Health (Baltimore)/ Medstar Georgetown University Hospital, Washington, District of Columbia, USA
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Valente M, Saab J, Cordato D, Manning N, Cappelen-Smith C. The diagnostic utility of routine clot analysis after endovascular thrombectomy in a patient with systemic lupus erythematosus and antiphospholipid syndrome. J Clin Neurosci 2019; 70:247-249. [PMID: 31540859 DOI: 10.1016/j.jocn.2019.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 08/17/2019] [Accepted: 09/04/2019] [Indexed: 11/19/2022]
Abstract
We present a case demonstrating histopathological clot findings after endovascular thrombectomy for acute ischaemic stroke in a 38 year-old male with systemic lupus erythematosus and antiphospholipid syndrome (APS). The differential diagnosis was embolism of a suspected Libman-Sacks vegetation or less likely an in-situ thrombosis. Clot analysis provided guidance with patient management and anticoagulation was commenced. The utility of clot analysis in this case provides support for routine clot analysis, which has been standard practice at our institution, and is likely to evolve as endovascular thrombectomy becomes more widely accessible.
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Affiliation(s)
- Michael Valente
- Department of Neurology & Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Jawad Saab
- Department of Anatomical Pathology, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Dennis Cordato
- Department of Neurology & Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia; Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, New South Wales, Australia
| | - Nathan Manning
- Department of Interventional Neuroradiology, Liverpool Hospital, Liverpool, New South Wales, Australia; Department of Interventional Neuroradiology, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Cecilia Cappelen-Smith
- Department of Neurology & Neurophysiology, Liverpool Hospital, Liverpool, New South Wales, Australia; Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia; South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, New South Wales, Australia.
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Zaman S, Rahim MA, Sayami LA, Nabi S, Islam AM, Ullah M. Libman-Sacks endocarditis in a Bangladeshi patient suffering from rhupus. Trop Doct 2019; 49:309-311. [PMID: 31180802 DOI: 10.1177/0049475519854623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Libman-Sacks endocarditis (LSE) is one of the most characteristic cardiac lesions in systemic lupus erythematosus (SLE). Patients may remain asymptomatic, while symptomatic patients often suffer with systemic emboli. These commonly test positive for anti-phospholipid antibody (aPA). The association of LSE with an overlap of rheumatoid arthritis (RA) and lupus (also known as 'rhupus') is rare. We report such a patient, who had been diagnosed as having RA seven years before and had suffered an acute ischaemic stroke one year previously and had echocardiographic evidence of LSE found during routine evaluation. However, she tested negative for aPA.
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Affiliation(s)
- Shahana Zaman
- Junior Consultant, Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh
| | - Muhammad Abdur Rahim
- Associate Professor, Department of Nephrology, Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka, Bangladesh
| | - Lima Asrin Sayami
- Junior Consultant, Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh
| | - Shaila Nabi
- Associate Professor, Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh
| | - Akm Monwarul Islam
- Associate Professor, Department of Cardiology, National Institute of Cardiovascular Diseases (NICVD), Dhaka, Bangladesh
| | - Mohammad Ullah
- Associate Professor, Department of Cardiology, Colonel Malek Medical College, Manikgonj, Bangladesh
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Role of Echocardiography in Assessment of Cardioembolic Sources: a Strong Diagnostic Resource in Patients with Ischemic Stroke. Curr Cardiol Rep 2018; 20:136. [PMID: 30310999 DOI: 10.1007/s11886-018-1085-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE OF REVIEW This review will discuss the most frequent sources of cardiac embolism and the role of echocardiography in these different clinical settings, and, in addition, provide suggestions about the choice between transthoracic (TTE) and transesophageal echocardiography (TEE). RECENT FINDINGS Stroke is the third leading cause of death in industrial countries, and 15-40% of all ischemic strokes are due to cardioembolism. TTE and TEE are cornerstones in the detection of cardioembolic sources and provide fundamental information about the embolic risk and most suitable treatment of these patients, improving long-term outcomes. Echocardiography is a widely available, inexpensive, and safe diagnostic tool that is almost free from contraindication, and these elements allow the common use of this technique in almost all the patients with ischemic stroke. The most common cardioembolic sources include left atrial appendage thrombosis during atrial fibrillation; vegetations in infective endocarditis; cardiac masses including left ventricular thrombosis, cardiac tumors, etc.; atherosclerotic plaques; and passageways within the heart serving as conduits for paradoxical embolization, e.g., patent foramen ovale.
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Abstract
Cardiovascular disease is an important extra-articular manifestation of rheumatologic diseases leading to considerable mortality and morbidity. Echocardiography emerges as a useful non-invasive technique for the screening and evaluation of cardiac involvement in these patients. With the technological advancement in echocardiographic techniques, we have gained a greater appreciation of the prevalence and nature of the cardiac involvement in these patients, as detection of subclinical disease is increasingly feasible. This review discusses cardiac involvement in patients with rheumatoid arthritis, systemic lupus erythematosus, anti-phospholipid antibody syndrome, systemic sclerosis and ankylosing spondylitis, and the role of different echocardiographic modalities in their evaluation.
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Affiliation(s)
- Maha A Al-Mohaissen
- Department of Clinical Sciences (Cardiology), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Kwan-Leung Chan
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, ON, Canada. .,University of Ottawa Heart Institute, 40 Ruskin Street, Room H3412, Ottawa, ON, K1Y 4W7, Canada.
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Vergara-Uzcategui CE, Donís JH. Endocarditis de Libman-Sacks en válvula mitral nativa. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2017; 87:231-233. [DOI: 10.1016/j.acmx.2017.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 04/04/2017] [Accepted: 04/04/2017] [Indexed: 11/27/2022] Open
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Caforio AL, Adler Y, Agostini C, Allanore Y, Anastasakis A, Arad M, Böhm M, Charron P, Elliott PM, Eriksson U, Felix SB, Garcia-Pavia P, Hachulla E, Heymans S, Imazio M, Klingel K, Marcolongo R, Matucci Cerinic M, Pantazis A, Plein S, Poli V, Rigopoulos A, Seferovic P, Shoenfeld Y, Zamorano JL, Linhart A. Diagnosis and management of myocardial involvement in systemic immune-mediated diseases: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Disease. Eur Heart J 2017; 38:2649-2662. [DOI: 10.1093/eurheartj/ehx321] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 05/24/2017] [Indexed: 02/06/2023] Open
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Generali E, Folci M, Selmi C, Riboldi P. Immune-Mediated Heart Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1003:145-171. [PMID: 28667558 DOI: 10.1007/978-3-319-57613-8_8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The heart involvement in systemic autoimmune diseases represents a growing burden for patients and health systems. Cardiac function can be impaired as a consequence of systemic conditions and manifests with threatening clinical pictures or chronic myocardial damage. Direct injuries are mediated by the presence of inflammatory infiltrate which, even though unusual, is one of the most danger manifestations requiring prompt recognition and treatment. On the other hand, a not well-managed inflammatory status leads to accelerated atherosclerosis that precipitates ischemic disease. All cardiac structures may be damaged with different grades of intensity; moreover, lesions can appear simultaneously or more frequently at a short distance from each other leading to the onset of varied clinical pictures. The pathogenesis of heart damages in systemic autoimmune conditions is not yet completely understood for the great part of situations, even if several mechanisms have been investigated. The principal biochemical circuits refer to the damaging role of autoantibodies on cardiac tissues and the precipitation of immune complexes on endocardium. These events are finally responsible of inflammatory infiltration which leads to subsequent worsening of the previous damage. For these reasons, it appears of paramount importance a regular and deepened cardiovascular assessment to prevent a progressive evolution toward heart failure in patient affected by autoimmune diseases.
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Affiliation(s)
- Elena Generali
- Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Marco Folci
- Allergy, Clinical Immunology and Rheumatology Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Carlo Selmi
- Rheumatology and Clinical Immunology, Humanitas Research Hospital, Rozzano, Milan, Italy.,BIOMETRA Department, University of Milan, Milan, Italy
| | - Piersandro Riboldi
- Allergy, Clinical Immunology and Rheumatology Unit, IRCCS Istituto Auxologico Italiano, Milan, Italy.
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Aby ES, Rosol Z, Simegn MA. Mitral Valve Perforation in Libman-Sacks Endocarditis: A Heart-Wrenching Case of Lupus. J Gen Intern Med 2016; 31:964-9. [PMID: 26976291 PMCID: PMC4945550 DOI: 10.1007/s11606-016-3640-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2015] [Revised: 12/30/2015] [Accepted: 02/12/2016] [Indexed: 11/28/2022]
Abstract
Libman-Sacks (LS) endocarditis is one of the most common cardiac manifestations of systemic lupus erythematosus. Rarely, however, it can lead to serious complications, including severe valvular regurgitation or superimposed bacterial endocarditis. We describe the initial diagnostic challenges, clinical course, imaging studies and histopathological findings of a patient who presented with life-threatening lupus complicated by hemoptysis and respiratory failure secondary to a rare complication of LS endocarditis, acute mitral valve perforation. We review the current literature on valve perforation in the setting of LS endocarditis. In conclusion, although the disease is often asymptomatic and hemodynamically insignificant, it can result in serious and potentially fatal complications secondary to valve perforation, which may demand emergency surgical management.
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Affiliation(s)
- Elizabeth S Aby
- Division of Internal Medicine, UCLA Medical Center, Los Angeles, CA, USA.
| | - Zachary Rosol
- Division of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN, USA
| | - Mengistu A Simegn
- Division of Cardiology, Hennepin County Medical Center, Minneapolis, MN, USA.
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