Libman–Sacks vegetations detected by 3D echocardiography

Libman–Sacks vegetations detected by 3D echocardiography 292 J.W. Sacre et al. 20. Ball J, Carrington MJ, Stewart S, SAFETY Investigators. Mild cognitive impairment 24. Alves TC, Rays J, Fraguas R Jr, Wajngarten M, Meneghetti JC, Prando S et al. in high-risk patients with chronic atrial fibrillation: a forgotten component of clin- Localized cerebral blood flow reductions in patients with heart failure: a study ical management?. Heart 2013;99:542–7. using 99mTc-HMPAO SPECT. J Neuroimaging 2005;15:150–6. 21. Cao L, Pokorney SD, Hayden K, Welsh-Bohmer K, Newby LK. Cognitive func- . 25. Elias MF, Sullivan LM, Elias PK, D’agostino RB Sr, Wolf PA, Seshadri S et al. Left tion: is there more to anticoagulation in atrial fibrillation than stroke? J Am Heart ventricular mass, blood pressure, and lowered cognitive performance in the Assoc 2015;4:e001573. Framingham offspring. Hypertension 2007;49:439–45. 22. Carvalho A, Rea IM, Parimon T, Cusack BJ. Physical activity and cognitive func- 26. Scuteri A, Coluccia R, Castello L, Nevola E, Brancati AM, Volpe M. Left ventricu- tion in individuals over 60 years of age: a systematic review. Clin Interv Aging . lar mass increase is associated with cognitive decline and dementia in the elderly 2014;9:661–82. independently of blood pressure. Eur Heart J 2009;30:1525–9. 23. Waldstein SR, Rice SC, Thayer JF, Najjar SS, Scuteri A, Zonderman AB. Pulse 27. Russo C, Jin Z, Homma S, Elkind MS, Rundek T, Yoshita M et al. Subclinical left pressure and pulse wave velocity are related to cognitive decline in the ventricular dysfunction and silent cerebrovascular disease: the Cardiovascular Baltimore Longitudinal Study of Aging. Hypertension 2008;51:99–104. Abnormalities and Brain Lesions (CABL) study. Circulation 2013;128:1105–11. IMAGE FOCUS doi:10.1093/ehjci/jex321 Online publish-ahead-of-print 30 December 2017 .................................................................................................................................................... 1,2 1 Nir Flint * and Robert J. Siegel 1 2 Heart institute, Cedars-Sinai Medical Center, 127 S San Vincente Blvd, AHSP A3417, Los Angeles, CA 90048, USA; and Department of Cardiology, Tel-Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann st., Tel-Aviv 6423906, Israel * Corresponding author. Tel: 11 310 423 3849; Fax: 11 310 423 4627. E-mail: nir.flint@cshs.org A 35-year-old woman with a history of systemic lupus erythematosus presented with symptoms of congestive heart failure. She was treated with diuretics with resolution of her dyspnoea. Laboratory testing revealed a white-cell count of 7300/mm , creatinine was 2.2 mg/dL, and C-reactive protein level was 10.2 mg/L (normal< 5). Repeated blood cultures were negative. Transthoracic echo demonstrated thickened mitral valve leaflets and severe mitral regurgitation. On 3D transoesophageal echocardiography, vegetations were observed on the atrial (Panel A, arrow) as well as the ventricular aspect (Panel B, arrows) of the posterior mitral leaflet, consistent with Libman–Sacks endocarditis (LSE). In their 1924 seminal paper Libman and Sacks described four patients with a new form of endocarditis identified at autopsy. It was charac- terized as ‘.. .free from demonstrable micro-organisms’, emphasizing that ‘.. .the lesions on the posterior cusp of the mitral valve were situated chiefly on the ventricular aspect of the valve’. 2D echocardiography primarily images the atrial aspect of the mitral valve leaflets and is limited in its abil- ity to image the valve from the ventricular side (see Supplementary data online, Videos S1 and S2). Hence LSE vegetations have been described on echocardiography as being on the atrial surface of the mitral valve leaflets. 3D echocardiography allows the visualization of the undersurface of the mitral valve. This enables the detection of vegetations on the ventricular aspect of the mitral valve (Panel B and Supplementary data online, Video 3) as originally described in Libman and Sacks’ autopsy case series (Panel C, arrowheads). This patient was discharged home for future surgical re-evaluation. Supplementary data are available at European Heart Journal—Cardiovascular Imaging online. Published on behalf of the European Society of Cardiology. All rights reserved. V The Author 2017. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/ehjcimaging/article-abstract/19/3/292/4682811 by Ed 'DeepDyve' Gillespie user on 22 March 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal – Cardiovascular Imaging Oxford University Press

Libman–Sacks vegetations detected by 3D echocardiography

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Abstract

292 J.W. Sacre et al. 20. Ball J, Carrington MJ, Stewart S, SAFETY Investigators. Mild cognitive impairment 24. Alves TC, Rays J, Fraguas R Jr, Wajngarten M, Meneghetti JC, Prando S et al. in high-risk patients with chronic atrial fibrillation: a forgotten component of clin- Localized cerebral blood flow reductions in patients with heart failure: a study ical management?. Heart 2013;99:542–7. using 99mTc-HMPAO SPECT. J Neuroimaging 2005;15:150–6. 21. Cao L, Pokorney SD, Hayden K, Welsh-Bohmer K, Newby LK. Cognitive func- . 25. Elias MF, Sullivan LM, Elias PK, D’agostino RB Sr, Wolf PA, Seshadri S et al. Left tion: is there more to anticoagulation in atrial fibrillation than stroke? J Am Heart ventricular mass, blood pressure, and lowered cognitive performance in the Assoc 2015;4:e001573. Framingham offspring. Hypertension 2007;49:439–45. 22. Carvalho A, Rea IM, Parimon T, Cusack BJ. Physical activity and cognitive func- 26. Scuteri A, Coluccia R, Castello L, Nevola E, Brancati AM, Volpe M. Left ventricu- tion in individuals over 60 years of age: a systematic review. Clin Interv Aging . lar mass increase is associated with cognitive decline and dementia in the elderly 2014;9:661–82. independently of blood pressure. Eur Heart J 2009;30:1525–9. 23. Waldstein SR, Rice SC, Thayer JF, Najjar SS, Scuteri A, Zonderman AB. Pulse 27. Russo C, Jin Z, Homma S, Elkind MS, Rundek T, Yoshita M et al. Subclinical left pressure and pulse wave velocity are related to cognitive decline in the ventricular dysfunction and silent cerebrovascular disease: the Cardiovascular Baltimore Longitudinal Study of Aging. Hypertension 2008;51:99–104. Abnormalities and Brain Lesions (CABL) study. Circulation 2013;128:1105–11. IMAGE FOCUS doi:10.1093/ehjci/jex321 Online publish-ahead-of-print 30 December 2017 .................................................................................................................................................... 1,2 1 Nir Flint * and Robert J. Siegel 1 2 Heart institute, Cedars-Sinai Medical Center, 127 S San Vincente Blvd, AHSP A3417, Los Angeles, CA 90048, USA; and Department of Cardiology, Tel-Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel-Aviv University, 6 Weizmann st., Tel-Aviv 6423906, Israel * Corresponding author. Tel: 11 310 423 3849; Fax: 11 310 423 4627. E-mail: nir.flint@cshs.org A 35-year-old woman with a history of systemic lupus erythematosus presented with symptoms of congestive heart failure. She was treated with diuretics with resolution of her dyspnoea. Laboratory testing revealed a white-cell count of 7300/mm , creatinine was 2.2 mg/dL, and C-reactive protein level was 10.2 mg/L (normal< 5). Repeated blood cultures were negative. Transthoracic echo demonstrated thickened mitral valve leaflets and severe mitral regurgitation. On 3D transoesophageal echocardiography, vegetations were observed on the atrial (Panel A, arrow) as well as the ventricular aspect (Panel B, arrows) of the posterior mitral leaflet, consistent with Libman–Sacks endocarditis (LSE). In their 1924 seminal paper Libman and Sacks described four patients with a new form of endocarditis identified at autopsy. It was charac- terized as ‘.. .free from demonstrable micro-organisms’, emphasizing that ‘.. .the lesions on the posterior cusp of the mitral valve were situated chiefly on the ventricular aspect of the valve’. 2D echocardiography primarily images the atrial aspect of the mitral valve leaflets and is limited in its abil- ity to image the valve from the ventricular side (see Supplementary data online, Videos S1 and S2). Hence LSE vegetations have been described on echocardiography as being on the atrial surface of the mitral valve leaflets. 3D echocardiography allows the visualization of the undersurface of the mitral valve. This enables the detection of vegetations on the ventricular aspect of the mitral valve (Panel B and Supplementary data online, Video 3) as originally described in Libman and Sacks’ autopsy case series (Panel C, arrowheads). This patient was discharged home for future surgical re-evaluation. Supplementary data are available at European Heart Journal—Cardiovascular Imaging online. Published on behalf of the European Society of Cardiology. All rights reserved. V The Author 2017. For permissions, please email: journals.permissions@oup.com. Downloaded from https://academic.oup.com/ehjcimaging/article-abstract/19/3/292/4682811 by Ed 'DeepDyve' Gillespie user on 22 March 2018

Journal

European Heart Journal – Cardiovascular ImagingOxford University Press

Published: Mar 1, 2018

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