Libman-Sacks endocarditis and associated cerebrovascular disease: The role of medical therapy

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.

Contemporary demographics, diagnostics and outcomes in non-bacterial thrombotic endocarditis

“…Other investigations, however, have reported that patients with SLE may have a threefold to fivefold increased in surgical morbidity and mortality 24 25. Moreover, conventional anti-inflammatory and antithrombotic therapy may obviate the need for high-risk valvular surgery 26. Despite this, many patients in our cohort were poor surgical candidates due to advanced age and comorbid conditions.…”

“…24 25 Moreover, conventional anti-inflammatory and antithrombotic therapy may obviate the need for high-risk valvular surgery. 26 Despite this, many patients in our cohort were poor surgical candidates due to advanced age and comorbid conditions. Only three (6.3%) patients underwent cardiac surgery; one of them died shortly after intervention and the others had no postoperative complications.…”

A 27-Year-Old Woman With Dysarthria

“…In a recent longitudinal and cross-sectional study, patients with SLE and Libman-Sacks endocarditis complicated by embolic cerebrovascular disease were treated with conventional anti-inflammatory and anti-thrombotic therapy for six months; on the follow-up TEE, 76% of the patients experienced resolved or improved valvular vegetation or regurgitation. 22 In another six-year longitudinal and cross-sectional study, 16% of patients had new or recurrent stroke, 14% had cognitive disability, and 9% died. 16 …”

All Endocarditis Is Not Infective: Libman-Sacks Endocarditis

“…Management of LSE and the usefulness of immunosuppressive for valvular regurgitation were not described in detail before in the pediatric age group but some evidence in the adult population [ 8 , 12 - 13 ]. For instance, Ishizu et al [ 10 ] reported a dramatic improvement after using immunosuppressive medication in LSE with severe mitral regurgitation.…”