Libman-Sacks Endocarditis: Detection, Characterization, and Clinical Correlates by Three-Dimensional Transesophageal Echocardiography

Abstract

Background Libman-Sacks endocarditis, characterized by Libman-Sacks vegetations, is common in patients with systemic lupus erythematosus (SLE), and is commonly complicated with embolic cerebrovascular disease. Thus, accurate detection of Libman-Sacks vegetations may lead to early therapy and prevention of their associated complications. Although two-dimensional transesophageal echocardiography (2D-TEE) has high diagnostic value for detection of Libman-Sacks vegetations, three-dimensional TEE (3D-TEE) may allow improved detection, characterization, and clinical correlations of Libman-Sacks vegetations. Methods 29 SLE patients (27 women, age 34±12 years) prospectively underwent 40 paired 3D-TEE and 2D-TEE studies and assessment of cerebrovascular disease manifested as acute clinical neurologic syndromes, neurocognitive dysfunction, or focal brain injury on MRI. Initial and repeat studies in patients were intermixed in a blinded manner with paired studies from healthy controls, de-identified, coded, and independently interpreted by experienced observers unaware of patients’ clinical and imaging data. Results 3D-TEE as compared to 2D-TEE studies were more often positive for mitral or aortic valve vegetations, detected more vegetations per study, and determined larger size of vegetations (all p≤0.03). Also, 3D-TEE detected more vegetations on the anterior mitral leaflet, anterolateral and posteromedial scallops, and ventricular side or both atrial and ventricular sides of the leaflets (all p<0.05). In addition, 3D-TEE detected more vegetations on the aortic valve left and non-coronary cusps, coronary cusps’ tip and margins, and aortic side or both aortic and ventricular sides of the cusps (all p≤0.01). Furthermore, 3D-TEE detected more often associated mitral or aortic valves’ commissural fusion (p=0.002). Finally, 3D-TEE detected more vegetations in patients with cerebrovascular disease (p=0.01). Conclusion 3D-TEE provides clinically relevant additive information that complements 2D-TEE for the detection, characterization, and association with cerebrovascular disease of Libman-Sacks endocarditis.

Nonbacterial Thrombotic Endocarditis—A Rare Case of Acute Libman-Sacks Endocarditis Complicated by Multiple Cerebral Infarcts: Case Report and Literature Review

“…The mean size of atrial thrombus caused by typical LSE is reported to be 3.9 ± 1.3 mm, with a maximum size of 10 mm, which is smaller than what was seen in our patient (29 mm). 14 Typical LSE sometimes involves not only one small thrombus but also multiple small thrombi. On the other hand, this patient had only one large thrombus.…”

Mitral Valve Perforation in Libman–Sacks Endocarditis: A Heart-Wrenching Case of Lupus

“…It is detected in 43 % of patients with SLE using transesophageal echocardiography (TEE). 4 Three-dimensional TEE may have an additive and complementary value in the detection of LS endocarditis, 6 which most commonly involves the mitral valve, followed by the aortic valve. 7 LS endocarditis has been reported to be associated with higher disease activity, longer disease duration, and positive anticardiolipin and antiphospholipid antibodies.…”

“…This is in contrast to the highly mobile, narrow-based infectious vegetations that tend to be homogeneous in echogenicity and associated with a variable degree of valvular insufficiency and perforation. 4,6 The modified Duke criteria are sensitive for the diagnosis of infectious endocarditis. However, these criteria do not help in distinguishing infective from non-infective endocarditis, as multiple criteria are shared by these two conditions.…”

Long-term Prognosis Analysis of PARACHUTE Device Implantation in Patients with Ischemic Heart Failure: A Single-Center Experience of Chinese patients

“…To achieve the highest spatial and temporal resolution, we obtained electrocardiographically triggered multiple-beat (4 beats) high-density full volume images with the narrowest possible sector scan during breath-holding (expiration). (10) Contrast echocardiography(11) was conducted following 2D-echocardiography in gray-scale ultraharmonic mode. Mean transmitting frequency and receiving frequency were 1.3 and 3.6 MHz, respectively.…”