Diagnosis and surgical treatment for isolated tricuspid Libman-Sacks endocarditis: a rare case report and literatures review

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Non-surgical extirpation of a non-infectious expanding tricuspid valve mass by percutaneous aspiration thrombectomy

Marantic endocarditis refers to a noninfectious lesion, usually in the aortic and mitral valves, that is most commonly seen in advanced malignancy and systemic lupus erythematosus. Inflammatory conditions, including antiphospholipid syndrome (APS), are a rare etiology making up less than 20% of reported cases. The condition is thought to be due to a hypercoagulable state and found postmortem with rates in autopsy series ranging from 0.9% to 1.6%. In comparison to infective endocarditis, marantic endocarditis has a greater tendency for valve vegetations to embolize. Common treatment modalities include anticoagulation or valve replacement. Although percutaneous aspiration thrombectomy of right-sided heart chamber thrombi exists, there are limited reports demonstrating its use with regards to treatment of right-sided endocarditis. We present the case of an older male with a history of Factor V Leiden and APS who was admitted due to a rapidly expanding mass on the tricuspid valve (TV). Despite serial blood cultures being negative, the patient received adequate antibiotic therapy for more than 4 weeks. Transthoracic echocardiogram showed an enlarged TV vegetation with an increased diameter from 10 to 30 mm over 6 weeks. Due to the patient's high operative risk and concern for embolization complications, a multidisciplinary decision was made to perform percutaneous aspiration thrombectomy of the TV vegetation. Subsequent biopsy of the lesion confirmed it was noninfectious and nonmalignant. Thus, the patient was started on systemic anticoagulation for prevention of thromboembolic events.

A Rare Case of Tricuspid Valve Libman–Sacks Endocarditis in a Pregnant Woman with Primary Antiphospholipid Syndrome

Antiphospholipid Antibody Syndrome (APS) is a systemic autoimmune disease characterized by acquired hypercoagulability with the possible development of venous, arterial, and microvascular thrombosis. We report a rare case of Libman–Sacks tricuspid valve endocarditis in a 38-year-old pregnant woman at 15 weeks gestation with unknown primary antiphospholipid syndrome. During a routine cardiac examination and echocardiography performed for a previous episode of pleuropericarditis, a large, mobile mass with irregular edges was found at the level of the tricuspid valve. Three main differential diagnoses for intramyocardial mass were examined: tumor, infective endocarditis, and nonbacterial thrombotic endocarditis (NTBE). Cardiac magnetic resonance imaging (CMR) with contrast raised the suspicion of a thrombus. The woman was hospitalized urgently at the Cardiac Intensive Care Unit of the Federico II University Hospital, and anticoagulant and antiplatelet therapy were started. The thrombophilic screening performed and medical history confirmed the diagnosis of primary antibody syndrome (APS). A multidisciplinary consultation with obstetricians, cardiologists, anesthetists, and cardiac surgeons was required. The patient decided not to terminate the pregnancy despite the risk to her health and to undergo cardiac surgery during pregnancy. Histological examination confirmed the presence of nonbacterial thrombotic endocarditis. Weekly obstetric scans were performed after surgery to verify fetal well-being. An emergency cesarean section was performed at the 35th week of gestation due to repeated deceleration and abnormal short-term variability on c-CTG in a pregnancy complicated by fetal growth restriction and gestational hypertension. A newborn weighing 1290 g was born. She was hospitalized in Neonatal Intensive Care and discharged after two months; currently, she enjoys good health. The management of patients with antiphospholipid antibody syndrome has not yet been standardized, but there is a general consensus that patients who do not have thrombocytopenia, thromboembolic phenomena, or pregnancy should not undergo any treatment or should take only low doses of acetylsalicylic acid. In the presence of any of the above conditions, various treatment regimens have been used based on the severity and individuality of the case.

Echocardiographic features in antiphospholipid-negative Sneddon's syndrome and potential association with severity of neurological symptoms or recurrence of strokes: a longitudinal cohort study

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.

Mitral Valve Repair for Isolated Libman-Sacks Endocarditis in a Patient with Primary Antiphospholipid Syndrome

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.

Multiple embolic strokes as a result of Libman–Sacks endocarditis associated with lupus and secondary antiphospholipid antibody syndrome: a case report

Background

Libman–Sacks endocarditis (LSE) is an infrequently recognized pathogenesis of embolic cerebrovascular disease. Patients often have asymptomatic valvular dysfunction which if not recognized promptly, can lead to serious complications such as heart failure, arrhythmias, cerebroembolic phenomena with increased neurocognitive disability, and even death. It can be associated with systemic lupus erythematosus and/or antiphospholipid antibody syndrome (APLS).

Case summary

Previously very healthy and active, 49-year-old Caucasian female with past medical history of mild lupus, for which she stopped treatment 10 year ago, saw a primary care physician complaining of intermittent double vision of 2 months duration. Urgent brain magnetic resonance imaging revealed multiple embolic infarcts of the brain stem. Further comprehensive work-up led to diagnosis of mitral LSE and APLS. After 2 months of systemic anticoagulation with warfarin and immunosuppressive therapy with hydroxychloroquine sulfate, repeat imaging demonstrated resolution of the mitral valve vegetation with no clinical recurrence of thromboembolic events at 6 months.

Discussion

Mild, often silent, autoimmune disease as described in our case can lead to significant cerebrovascular disease. Patients who present with cryptogenic strokes with high suspicion of underlying autoimmune disease should be worked up thoroughly for possible valvular heart disease associated with lupus, APLS, or both. Acquisition of transoesophageal images proved superior to transthoracic approach and it should be implemented in these subsets of patients. With this case report, we highlight the importance of early recognition of cardiac manifestations, amelioration of risk factors, as well as close follow-up of lupus or APLS patients, as crucial steps in reducing their morbidity and mortality along with preventing recurrence or progression of cerebrovascular disease.

Nonbacterial Thrombotic Endocarditis of the Tricuspid Valve in a Male Patient with Antiphospholipid Syndrome

Valve vegetations in nonbacterial thrombotic endocarditis consist of fibrin and platelet aggregates and can be related to circulating immune complexes, such as in the case of antiphospholipid syndrome. In patients with primary antiphospholipid syndrome, echocardiographic studies have disclosed heart valve abnormalities in about a third of patients. Unusual associations between antiphospholipid syndrome and nonbacterial thrombotic endocarditis include presentation as an intracardiac mass compatible with a myxoma on imaging studies, as well as isolated involvement of the tricuspid valve. Both of these scenarios have been previously reported in female patients. This article presents the case of a 53-year-old Hispanic male with antiphospholipid syndrome who presented to the hospital with symptoms of heart failure and persistent right calf pain. An intracardiac mass attached to the anterior leaflet of the tricuspid valve was found through transthoracic echocardiography. Further imaging studies suggested the mass to be a myxoma and the patient underwent mass excision with tricuspid valve replacement. Pathology report of the surgical specimen was consistent with a diagnosis of nonbacterial thrombotic endocarditis. This case highlights the importance of considering nonbacterial thrombotic endocarditis as a key differential diagnosis in patients with concomitant antiphospholipid syndrome and intracardiac masses, as well as challenges encountered in diagnosis and management.