Mitral Valve Surgery in Patients with Systemic Lupus Erythematosus

Abstract

Valvular heart disease is the common cardiac manifestation of systemic lupus erythematosus (SLE) with a tendency for mitral valve regurgitation. In this study we report a case of mitral valve replacement for mitral stenosis caused by Libman-Sacks endocarditis in the setting of SLE. In addition, we provide a systematic review of the literature on mitral valve surgery in the presence of Libman-Sacks endocarditis because its challenge on surgical options continues. Surgical decision depends on structural involvement of mitral valve and presence of active lupus nephritis and antiphospholipid antibody syndrome. Review of the literature has also shown that outcome is good in most SLE patients who have undergone valvular surgery, but association of antiphospholipid antibody syndrome with SLE has negative impact on the outcome.

Catastrophic antiphospholipid syndrome after cardiac surgery

“…We believe that the requirement for two positive APL tests 12 weeks apart to diagnose and treat APS is an artificial convention (designed to avoid overtreatment of patients with transient positive APL without other clinical sequelae associated with APS), which may delay diagnosis and treatment in patients similar to one presented where an initial positive APL can lead to CAPS in less than 12 weeks. Treatment of CAPS (and potentially precedent APS) can include anticoagulation, immunosuppression with methylprednisolone and cyclophosphamide, plasma exchange, and/or immunoglobulins . Our patient is not unusual in that she did not meet the strict criteria for APS preoperatively or postoperatively, even 20 days postoperatively when she was already in extremis from CAPS …”

“…There is little evidence about the effectiveness of novel oral anticoagulation medication such as rivaroxaban versus warfarin. In addition, there is no clear evidence for the preference between biological versus mechanical valve prostheses in APS patients, although pannus and thrombosis of biological valves has been reported, and mechanical valve thrombosis is a rare but known phenomenon. This patient chose a bioprosthesis to allow future pregnancy.…”

The association between systemic lupus erythematosus and valvular heart disease: an extensive data analysis

“…SLE associated with renal failure (lupus nephritis) can accelerate deterioration of the structural valves secondary to abnormal calcium and phosphate metabolism [28,29]. However, patients who are with low risk for bleeding under anticoagulation therapy and high risk for biologic valve calcification are recommended for mechanical valve replacement [30]. However, patients who are with low risk for bleeding under anticoagulation therapy and high risk for biologic valve calcification are recommended for mechanical valve replacement [30].…”

“…If renal involvement is prominent feature in SLE patient, the use of mechanical valves provides better results, although the risk of thromboembolic events remains [29]. However, patients who are with low risk for bleeding under anticoagulation therapy and high risk for biologic valve calcification are recommended for mechanical valve replacement [30]. Valve insufficiency (such as improper closure mechanism due to fibrosis/thickening, valve deformity and nodular vegetations) is the predominant expression in SLE patients, while stenosis and chordal apparatus involvement is uncommonly encountered [31].…”

Dyspnoea in lupus

“…Ultimately some patients may even require valve surgery (1%–8%). Based on case reports, stenosis should be treated surgically either by repair or replacement of the MV 11. In this case, given the severity of MS, valve replacement was definitely indicated.…”