Medline ® Abstracts for References 11,12
of 'Nonbacterial thrombotic endocarditis'
An echocardiographic study of valvular heart disease associated with systemic lupus erythematosus.
Roldan CA, Shively BK, Crawford MH
N Engl J Med. 1996;335(19):1424.
BACKGROUND: Valvular heart disease is the most important cardiac manifestation of systemic lupus erythematosus. We performed a study to determine the relation of valvular disease to other clinical features of lupus, whether or not the valve disease progresses, and the associated morbidity and mortality.
METHODS: We performed transesophageal echocardiography and rheumatologic evaluations in 69 patients with systemic lupus erythematosus. The echocardiographic findings were compared with those in 56 healthy volunteers. Fifty-eight patients (84 percent) had second evaluations a mean (+/-SD) period of 29 +/- 13 months later. The patients and controls were followed for 57 months.
RESULTS: Valvular abnormalities were common on the initial and the follow-up echocardiograms (in 61 and 53 percent of the patients, respectively). Valvular thickening was the predominant finding initially and on follow-up (in 51 and 52 percent of the patients, respectively), followed by vegetations (in 43 and 34 percent), valvular regurgitation (in 25 and 28 percent), and stenosis (in 4 and 3 percent). Valvular abnormalities frequently resolved, appeared for the first time, or persisted but changed in appearance or size between the two studies. Mild or moderate valvular regurgitation did not progress to become severe, and new stenoses did not develop. Neither the presence of valvular disease nor changes in the echocardiographic findings were temporally related to the duration, activity, or severity of lupus or to its treatment. The combined incidence of stroke, peripheral embolism, heart failure, infective endocarditis, and the need for valve replacement was 22 percent in the patients with valvular disease, but only 8 percent in those without it. A total of seven patients died during follow-up, in most cases as a result of valvular disease. Valvular abnormalities and complications were uncommon in the controls (occurring in 9 and 2 percent, respectively).
CONCLUSIONS: Valvular heart disease is common in patients with systemic lupus erythematosus, frequently changes over time, appears to be temporally unrelated to other clinical features of lupus, and is associated with substantial morbidity and mortality.
University of New Mexico Health Sciences Center and Veterans Affairs Medical Center, Albuquerque 87108, USA.
Transthoracic versus transesophageal echocardiography for detection of Libman-Sacks endocarditis: a randomized controlled study.
Roldan CA, Qualls CR, Sopko KS, Sibbitt WL Jr
J Rheumatol. 2008;35(2):224. Epub 2007 Dec 15.
OBJECTIVE: Libman-Sacks endocarditis in patients with systemic lupus erythematosus (SLE) is complicated with thromboembolism, severe valve regurgitation, need for high-risk valve surgery, or death. Transesophageal echocardiography (TEE) is highly accurate for detection of valvular heart disease, but there are no prospective randomized controlled series comparing transthoracic echocardiography (TTE) to TEE for detection of Libman-Sacks endocarditis.
METHODS: Eighty-one patients with SLE (73 women, 8 men) with a mean age of 39 +/- 11 years and 75 healthy volunteers (40 women, 35 men) with a mean age of 35 +/- 9 years underwent paired TTE and TEE to detect valve vegetations, thickening, or>or= moderate mitral, tricuspid, or pulmonic>or= mild aortic regurgitation. Paired TTE and TEE studies of patients and controls were randomized and interpreted by an experienced observer unaware of subjects' data.
RESULTS: Libman-Sacks endocarditis: (1) was more common in patients than in controls by both TTE and TEE (p<0.001); and (2) wasmore commonly detected by TEE than by TTE (p</= 0.05); (3) TTE and TEE demonstrated poor agreement rates (kappa 0.02-0.54); and (4) considering TEE as the standard, TTE demonstrated a low sensitivity (63% overall, 11% for valve vegetations), low specificity (58%), low negative predictive value (40%), and a moderate positive predictive value (78%) for detection of Libman-Sacks endocarditis.
CONCLUSION: TEE is superior to TTE for detection of Libman-Sacks endocarditis and should be considered either as complement to a nondiagnostic TTE or as the initial test in patients with SLE with suspected cardioembolism, acute or subacute Libman-Sacks endocarditis with moderate or worse valve dysfunction, or superimposed infective endocarditis.
Department of Internal Medicine and Cardiology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA. firstname.lastname@example.org