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Gartshteyn Y, Bhave N, Joseph MS, Askanase A, Bernstein EJ. Inflammatory and thrombotic valvulopathies in autoimmune disease. Heart 2023; 109:583-588. [PMID: 36288923 DOI: 10.1136/heartjnl-2021-319603] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 10/12/2022] [Indexed: 11/04/2022] Open
Abstract
Rheumatologic diseases are characterised by loss of immune tolerance, resulting in systemic inflammation. Inflammation and scarring of the endocardium, which lines the inner surface of the heart chambers and valves, can result in valvular thickening and dysfunction. Estimates of prevalence vary depending on the sensitivity of the screening methodology used and range from 30%-50% in systemic lupus and rheumatoid arthritis to 10%-30% in ankylosing spondylitis. Progression of valve disease is a slow process but can result in haemodynamically significant complications. Thromboembolic complications such as cerebrovascular occlusions pose a serious risk of morbidity. The presence of antiphospholipid antibodies increases the risk of valvular disease and thrombotic complications. Anticoagulation is recommended in the presence of antiphospholipid antibodies, but the guidance on the role of immunosuppressive therapy to treat valvular disease is lacking. Surgical valve therapy may be considered in severe disease, but there is increased risk in patients with an autoimmune disease which includes a higher risk of infection, thromboembolic and bleeding complications, as well as cardiovascular events in the setting of premature atherosclerotic heart disease. Therefore, management should be provided in a multidisciplinary team that includes a rheumatologist, a cardiologist and a cardiothoracic surgeon; medical therapy should be optimised before considering a high-risk valve surgery.
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Affiliation(s)
| | - Nicole Bhave
- Medicine, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Megan Shetty Joseph
- Medicine, University of Michigan Michigan Medicine, Ann Arbor, Michigan, USA
| | - Anca Askanase
- Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Elana J Bernstein
- Medicine, Columbia University Irving Medical Center, New York, New York, USA
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Quintero-Martinez JA, Hindy JR, El Zein S, Michelena HI, Nkomo VT, DeSimone DC, Baddour LM. Contemporary demographics, diagnostics and outcomes in non-bacterial thrombotic endocarditis. Heart 2022; 108:heartjnl-2022-320970. [PMID: 35534050 DOI: 10.1136/heartjnl-2022-320970] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/14/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Non-bacterial thrombotic endocarditis (NBTE) is a syndrome characterised by cardiac valve vegetations and/or thickening due to non-infective mechanisms. Nowadays, a premortem diagnosis of NBTE is possible based on echocardiographic findings. Therefore, to better characterise this disease, we performed a contemporary review of the epidemiology, demographics, diagnosis and clinical outcomes of these patients. METHODS Adults with a diagnosis of NBTE seen within the Mayo Clinic Enterprise from December 2014 to December 2021 were included. NBTE diagnosis was identified by clinicians representing at least two specialties including cardiology, infectious diseases, rheumatology and oncology. Patients with positive blood cultures, infective endocarditis, culture-negative endocarditis and denial of research authorisation were excluded. All patients had a 1-year follow-up. RESULTS Forty-eight cases were identified; mean age was 60.0±13.8 years, 75% were female. The most prevalent comorbidities were malignancy (52.1%) and connective tissue disease (37.5%). Valvular abnormalities included 41 (85.4%) patients with vegetations, 43 (89.6%) patients with thickening and 26 (54.2%) with moderate to severe regurgitation. Thirty-eight (79.2%) patients had an embolic event (stroke in 26 (54.2%) patients) within 1 month of NBTE diagnosis and 16 (33.3%) patients died within 1 year of NBTE diagnosis. Metastatic tumours and lung cancer were associated with 1-year all-cause mortality (p=0.0017 and p=0.0004, respectively). CONCLUSIONS NBTE was more prevalent in females and embolic complications were the most frequent clinical finding. Overall, patients with NBTE had a poor prognosis, particularly in those with lung cancer or metastatic tumours. Further studies in patients with NBTE are needed given its morbidity and mortality.
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Affiliation(s)
- Juan A Quintero-Martinez
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
- Department of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Joya-Rita Hindy
- Department of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Said El Zein
- Department of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Hector I Michelena
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Daniel C DeSimone
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
- Department of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Larry M Baddour
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
- Department of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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A Case of Systemic Lupus Erythematosus in a Patient Presenting with Libman-Sacks Endocarditis. Case Rep Cardiol 2021; 2021:5573141. [PMID: 34513093 PMCID: PMC8424240 DOI: 10.1155/2021/5573141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 08/20/2021] [Indexed: 11/17/2022] Open
Abstract
Background Libman-Sacks endocarditis (LSE) is a rare cardiovascular manifestation of systemic lupus erythematosus/antiphospholipid syndrome that is described as a sterile verrucous nonbacterial vegetative lesion. These lesions can cause progressive damage to the heart valves leading to valve surgery. The most common valves to be affected are the aortic and mitral valves. Libman-Sacks endocarditis is associated with malignancies, other systemic diseases like systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APS). The majority of LSE patients are usually asymptomatic. Case Summary. We describe a 39-year-old male patient who presented with increasing shortness of breath and pulmonary congestion. He was found to have severe mitral valve regurgitation and mitral stenosis. Transesophageal echocardiogram confirmed the diagnosis of Libman-Sacks endocarditis with thickened mitral valve leaflets with symmetrical mass-like structure causing a restriction in the valve function during both cardiac phases later diagnosed with systemic lupus erythematosus by immunology. The patient was started on diuretics, anticoagulants, angiotensin inhibitors, beta-blockers, and hydroxychloroquine. He underwent successful mechanical mitral valve replacement with a 27 mm St. Jude valve. The mitral valve was found to be grossly thickened with friable tissue and complete amalgamation of the leaflets with subvalvular apparatus. The patient suffered some warfarin adverse effects a year later but did well otherwise. Conclusion This case demonstrates that Libman-Sacks endocarditis can be the first manifestation of systemic lupus erythematosus. Early and prompt diagnosis of LSE can prevent and lessen the many side effects associated with thromboembolism. Additionally, addressing the underlying disease is key to successful treatment.
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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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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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Imaging for screening cardiovascular involvement in patients with systemic rheumatologic diseases: more questions than answers. Eur Heart J Cardiovasc Imaging 2019; 20:967-978. [DOI: 10.1093/ehjci/jez171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 05/30/2019] [Accepted: 06/04/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Cardiovascular involvement due to systemic rheumatologic diseases (SRDs) remains largely underdiagnosed despite causing excess mortality and limiting the favourable effect of therapeutic developments on survival. Traditional risk scoring systems are poorly calibrated for SRD patients. There is an unmet need to develop a cardiovascular (CV) risk stratification tool and screening algorithm for CV involvement dedicated to asymptomatic patients with SRDs. Even though accelerated atherosclerosis is the most prominent cause of major CV events, a more comprehensive approach is crucial to detect different pathological processes associated with SRDs that are leading to CV complications. In that regard, incorporation of imaging parameters obtained from echocardiography and carotid ultrasound (CUS) might help to improve risk models, to detect and monitor subclinical CV involvement. These two imaging modalities should be an integral part of screening SRD patients with suspicion of CV involvement on top of electrocardiogram (ECG). Cardiac magnetic resonance and multi-slice computerized tomography angiography and nuclear imaging modalities seem very important to complement echocardiography and CUS for further evaluation. However, to answer the question ‘Should asymptomatic patients with SRDs undergo screening with echocardiography and CUS on top of ECG?’ necessitates large studies performing cardiac screening with a standard approach by using these imaging methods to obtain longitudinal data with hard CV outcomes.
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Nakasu A, Ishimine T, Yasumoto H, Tengan T, Mototake H. Mitral valve replacement for Libman-Sacks endocarditis in a patient with antiphospholipid syndrome secondary to systemic lupus erythematosus. J Surg Case Rep 2018; 2018:rjy069. [PMID: 29644046 PMCID: PMC5888647 DOI: 10.1093/jscr/rjy069] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 02/26/2018] [Accepted: 03/22/2018] [Indexed: 11/17/2022] Open
Abstract
Libman–Sacks endocarditis is a relatively rare sterile verrucous vegetative lesion observed in systemic lupus erythematosus (SLE)/antiphospholipid syndrome (APLS) patients. Most patients with this condition are asymptomatic. Here we report a case of a 46-year-old woman with APLS secondary to SLE complicated with frequent thromboembolic events due to a mitral valve mass. We performed minimally invasive mitral valve replacement with a mechanical prosthetic valve, and she was successfully discharged 14 days after surgery. Thus, Libman–Sacks endocarditis may be an indication for mitral valve replacement.
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Affiliation(s)
- Akio Nakasu
- Department of Cardiovascular Surgery, Okinawa Chubu Hospital, Okinawa, Japan
| | - Tohru Ishimine
- Department of Cardiovascular Surgery, Okinawa Chubu Hospital, Okinawa, Japan
| | - Hiroshi Yasumoto
- Department of Cardiovascular Surgery, Okinawa Chubu Hospital, Okinawa, Japan
| | - Toshiho Tengan
- Department of Cardiovascular Surgery, Okinawa Chubu Hospital, Okinawa, Japan
| | - Hidemitsu Mototake
- Department of Cardiovascular Surgery, Okinawa Chubu Hospital, Okinawa, Japan
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Abstract
A 32-year-old woman suffering from systemic lupus erythematosus presented with a 6-week history of progressive dyspnoea and pleuritic chest pain. Examination was normal apart from reduced air entry at the lung bases.Arterial blood gases showed hypoxaemia and chest X-ray revealed raised hemidiaphragms without any pleural effusions. Lung function showed a restrictive pathology while high-resolution chest CT and CT pulmonary angiogram were negative. Echocardiography showed normal ventricular diameters and no pericardial effusion. Reduced lung volumes and a positive fluoroscopic sniff test lead to a diagnosis of shrinking lung syndrome. Symptoms improved following treatment with glucocorticoids and non-invasive ventilation, but there was no change in lung function.A year later, our patient presented again with worsening dyspnoea. This time echocardiography revealed severe mitral stenosis with pulmonary hypertension. Mitral valve replacement was performed and dyspnoea resolved. Histology showed Libman-Sachs endocarditis.
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Affiliation(s)
| | - Andrew Borg
- Department of Rheumatology, Mater Dei Hospital, Msida, Malta
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Watad A, Tiosano S, Grysman N, Comaneshter D, Cohen AD, Shoenfeld Y, Amital H. The association between systemic lupus erythematosus and valvular heart disease: an extensive data analysis. Eur J Clin Invest 2017; 47:366-371. [PMID: 28295225 DOI: 10.1111/eci.12744] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 03/06/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Association between antiphospholipid syndrome in systemic lupus erythematosus (SLE) and valvular heart disease (VHD) is well reported, but relatively few studies have been carried out to establish the linkage between VHD and SLE itself. We aimed to investigate link between VHD and SLE and to evaluate the association of diverse factors with VHD among these patients in a large-scale population-based study. MATERIALS AND METHODS We used the databases of the largest state-mandated health service organization in Israel. All SLE patients were included (n = 5018) as well as their age and sex-matched controls (n = 25 090), creating a cross-sectional population-based study. Medical records of all subjects were analysed for documented VHD and the presence of antiphospholipid antibodies (aPLs). A logistic regression model was carried out to evaluate the diverse factors including SLE and aPLs as independent risk factors for VHD. RESULTS Valvular heart disease were found to be more frequent among SLE group when compared to controls (aortic stenosis, 1·08% vs. 0·35% respectively, P < 0·001; aortic insufficiency, 1·32% vs. 0·29% respectively, P < 0·001; mitral stenosis, 0·74% vs. 0·21% respectively, P < 0·001; mitral insufficiency, 1·91% vs. 0·39% respectively, P < 0·001). Male sex, hypertension, aPLs and SLE were found to be significant independent risk factors for VHD. CONCLUSION All VHD are more prevalent among SLE patients when compared to controls. SLE and aPLs are independent risk factor for VHD (OR of 2·46 and 1·7, respectively). Physicians must be aware of such significant association, and routine echocardiography should be considered in SLE patients regardless of their aPL status.
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Affiliation(s)
- Abdulla Watad
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel.,Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Shmuel Tiosano
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Noam Grysman
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | - Arnon D Cohen
- Chief Physician's Office, Clalit Health Services, Tel-Aviv, Israel.,Siaal Research Center for Family Medicine and Primary Care, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Howard Amital
- Department of Medicine 'B', Sheba Medical Center, Tel-Hashomer, Israel.,Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Cardiac surgery in systemic lupus erythematosus patients: Clinical characteristics and outcomes. ACTA ACUST UNITED AC 2017; 14:269-277. [PMID: 28291723 DOI: 10.1016/j.reuma.2017.01.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 12/18/2016] [Accepted: 01/26/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To study the clinical characteristics and outcomes in systemic lupus erythematosus (SLE) patients who underwent cardiac surgery. METHODS Retrospective analysis of 30 SLE patients who underwent cardiac surgery at a single center. Demographics, comorbidities, clinical and serologic characteristics, cardiovascular risk scores and treatment were recorded. Type of surgery, postoperative complications, mortality and histology were analyzed. RESULTS Disease duration at surgery was 2 years. Valve replacement was the procedure most frequently performed (53%), followed by pericardial window (37%). At least one postoperative complication developed in 63% (mainly infections). An aortic cross-clamp time≥76minutes was associated with at least one postoperative complication (OR 6.4, 95% CI 1.1-35.4, p=.03). Early death occurred in 5 patients (17%) and late in 3 (10%); main causes were sepsis and heart failure. Disease activity was associated with pericardial window (OR 12.6, 95% CI 1.9-79, p=.007); lymphopenia≤1.200 (OR 10.1, 95% CI 1.05-97, p=.04); age≤30 years (OR 7.7, 95% CI 1.2-46.3, p=.02); and New York Heart Association class III (OR 7.0, 95% CI 1.1-42, p=.03). Postoperative infection was associated with length of hospital stay≥2 weeks (OR 54.9, 95% CI 5.0-602.1, p=.001); intensive care unit stay≥10 days (OR 20, 95% CI 1.6-171.7, p=.01); duration of mechanical ventilation≥5 days (OR 16.9, 95% CI 1.5-171.7, p=.01); and pulmonary artery systolic pressure≥50mmHg (OR 7.8, 95% CI 1.4-41.2, p=.01). CONCLUSIONS Cardiac surgery in SLE confers high morbidity and mortality. SLE-specific preoperative risk scores should be designed to identify prognostic factors.
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Sukniam KB, Proia AD, Glower DD. Catastrophic antiphospholipid syndrome after cardiac surgery. J Card Surg 2016; 31:584-6. [DOI: 10.1111/jocs.12811] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
| | - Alan D. Proia
- Duke University Medical Center; Durham North Carolina
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12
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Immunological and inflammatory processes in systemic autoimmune disease may not only cause pericardium inflammation, but may also cause mitral valve deterioration and left ventricular wall thickening. Int J Cardiol 2016; 215:466-71. [PMID: 27131766 DOI: 10.1016/j.ijcard.2016.04.126] [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: 01/14/2016] [Revised: 04/12/2016] [Accepted: 04/13/2016] [Indexed: 11/22/2022]
Abstract
PURPOSE Systemic autoimmune disease (SAD) frequently affects the pericardium, and pathology is characterized by both immunological and inflammatory processes. We hypothesized that these processes simultaneously influence mitral-valve (MV) deterioration and left-ventricular (LV) wall thickening in SAD subjects. METHODS 101 SAD subjects were selected (76 female; 53±17years; systemic-lupus-erythematosus, 26%; vasculitis, 20%; scleroderma, 14%; polymyositis/dermatomyositis complex, 10%; mixed connective tissue disease, 11% and rheumatoid-arthritis, 2%). MV anterior-mitral-leaflet (AML) length, AML thickness index, AML doming height and LV mass index (LVMI) were measured using transthoracic-echocardiography (TTE) and the presence of MV calcification, MV sub-valvular thickening and pericardial effusion (PE) were estimated. AML thickness index was calculated as the ratio of AML thickness to aortic posterior wall thickness. The correlation between LVMI and ECG V1S+V5R voltage was used to assess the etiology of LV wall thickening. RESULTS 19 subjects (19%) had significant PE. PE subjects had a significantly greater AML thickness index (1.55±0.48 vs. 1.14±0.32, P<0.001), AML doming height (1.26±1.54mm vs. 0.03±0.91mm, P<0.001), more frequent MV sub-valvular thickening (26% vs. 5%, P=0.003) and greater LVMI (104.7±34.6g/m2 vs. 80.6±21.0g/m2, P=0.002). Significant correlation was observed between LVMI and ECG V1S+V5R voltage in 79 subjects without PE (R=0.39, P<0.001). However, in 18 subjects with PE, no such correlation was observed (R=0.30, P=0.23). CONCLUSIONS MV, MV sub-valvular deterioration and increased LVMI, unrelated to high voltage ECG criteria, were frequently detected in SAD subjects with PE. Immunological and inflammatory processes in SAD may not only cause pericardium inflammation, but may also cause MV deterioration and LV wall thickening.
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