Presentation on theme: "Valvular Involvement in SLE Christopher G. Stephenson, MD, FACC The Sanger Clinic, PA."— Presentation transcript:
Valvular Involvement in SLE Christopher G. Stephenson, MD, FACC The Sanger Clinic, PA
Acknowlegements Sreekanth Reddy, MD Hematology/Oncology Atlanta Cancer Care Douglas Murphy, MD Cardiothoracic surgeon Peachtree Cardiovascular & Thoracic Surgeons, PA
Case Presentation—Initial admission (11/18/2004) of C.P. to Northside Hospital Forsyth (Cummings, GA) 26 y/o m with pmhx of SLE, aPL (+ IgG, IgM; + LAC), idiopathic cardiomyopathy (reportedly resolved), thrombocytopenia (~100K) in USOGH working as 6 th grade math teacher p/w LUQ pain “stabbing” in nature for several days, low grade fever (Tmax 101F) PShx: None Social hx: No tobacco, EtOH, or injection drug use Heterosexual, not sexually active Meds: CellCept 1gr BID Plaquenil 200mg QD Coreg 25mg BID Altace Prednisone 5mg QD
Initial evaluation revealed: Severe thrombocytopenia (20K) CT abdomen (IV contrast)—splenic infarct Multiple sets of blood cultures drawn prior to administration of empiric antibiotics---Negative Initial impression: aPL-associated thrombocytopenia and thrombosis Treatment: ASA High dose Prednisone Lovenox/Coumadin not administered due to thrombocytopenia
Readmission 11/24/2004 (2 days after discharge) with eventual transfer to St. Joseph’s Hospital of Atlanta, GA Presented with protracted nausea, emesis, epigastric pain, low grade fever, stable vitals. Severe thrombocytopenia (11K) WBC 7.7; Hct 32; UA 300mg/dl protein, RBCs; Creatinine 2.8 (etiology never ascertained—eventually normalized) Blood cultures from 11/19 and 11/23—No growth CXR-unremarkable ECG—NSR, LAE, Nl axis, Nl intervals, No ST/T changes No SOB, CP, or neurological symptoms PhysEx: Pectus Excavatum, II/VI axilla; No S3; No rub/click; abdomen benign, No stigmata of SBE, No petechiae Right inferior quadrantanopia
Echocardiogram--TTE View Study Note: TEE was subsequently performed which, by virtue of its poor quality and limited Doppler data added no incremental information to the TTE.
TTE findings Mild LA (43mm), LV (59mm) enlargement Inferior wall hypokinesis (TEE corroborated this finding) LVEF~45% Valvular “vegetation” (~0.5cm), non- mobile affixed to anterior leaflet of MV. No evidence of prolapse. Probable severe MR by color Doppler, although limited data to assess severity of MR; jet directed centrally
MRI brain/MRA intracranial arteries Show images Multiple, small diffusion abnormalities in the cerebral hemispheres evident in the frontal, parietal and occipital lobes bilaterally. Multiple small “embolic” bland infarctions Normal MRA of the intracranial circulation
Problem List 1) Splenic infarct 2) Multiple, bilateral cerebral hemispheric infarcts, likely embolic in origin 3) MV vegetation of indeterminate etiology (persistently culture-negative including fastidious pathogens) with associated severe MR 4) Severe thrombocytopenia, resistant to high dose steroids, IVIg, platelet transfusions 5) Anemia with evidence of hemolysis (Elevated LDH—1160, + schistocytes) 6) SLE/immunocompromised state 7) aPL Ab + LAC—possible hypercoaguable state/APS 8) ARF; proteinuria, and hematuria 9) Inferior wall hypokinesis/mild LV systolic dysfuction— cardiac cath not performed
Questions? Can we apply William of Occam’s principle of parsimony to this case? Is there a unifying diagnosis? How do we proceed? a) Resurrect Sir William Osler, then consult him. b) Transfer the patient to CMC/Carolinas Heart Institute for further evaluation and management. c) When in doubt, choose C o Any thoughts/suggestions?
Choice C—Call a CT surgeon Photos courtesy of Douglas A. Murphy, MD
Anterior leaflet of MV, with destruction of the edge of A2 causing central MR. Large nodule to right of A2 with multiple friable vegetations—Leaflet and chordae excised (not amenable to repair) and replaced with #33 ATS valve
Posterior MV leaflet with multiple friable vegetations along leaflet edge
Pathology report Largest excrescence on submitted MV tissue measured 10x6mm. Large verrucous fibrin deposit with scattered inflammatory cells. Striking fibrinoid necrosis at the base and within the valve. Nodular areas of fibrosis and dystrophic calcification. Special stains for AFB, fungi and bacteria-negative Diagnosis: Nonbacterial verrucous valvulitis of Libman-Sacks
Patient 3 weeks Post-op Laboratory Data 1/03/05 Hct=39 Platelets=333 Creatinine=1.3 PT=33.6 Patient returned to work as 6 th grade math teacher!
Valvular disease in SLE Leaflet thickening tends to be diffuse; it usually involved the mitral and aortic valves and is associated with valve regurgitation (~75%) or valve masses (50%). Lupus valve disease is frequent (75%) regardless of the presence or absence of antiphospholipid antibodies. Antiphospholipid antibodies may not be a primary pathogenetic factor.
An echocardiographic study of valvular heart disease associated with systemic lupus erythematosus TEE and rheumatologic evaluations in 69 patients with SLE Echocardiographic findings were compared with those in 56 healthy volunteers 84 % had second evaluations a mean period of 29 months later Patients and controls were followed for 57 months Roldan CA, et al. N Engl J Med 1996 Nov 7;335(19):
SLE echocardiographic study-- Conclusions Neither the presence of nor changes in valvular disease were temporally related to disease activity, therapy, or the duration of SLE. Appreciable incidence of serious complications in the patients with valvular disease. After a mean follow-up of almost five years, the combined incidence of stroke, peripheral embolism, heart failure, infective endocarditis, and death was 22% (with valve disease) vs 15% (without valvular disease). The incidence of stroke in patients with valvular disease was 13 percent.
Valvular disease in SLE—Clinical course 5 year follow-up—20% risk of valve related complications: Symptomatic severe MR Infective endocarditis Ischemic stroke Mortality 20% at 5yrs. Due to refractory heart failure, IE, CVA, complicated post-op course
Verrucous endocarditis Libman-Sacks (verrucous) endocarditis is a not uncommon complication of SLE Higher frequency (43 percent) has been noted when more sensitive transesophageal echocardiography is performed
Verrucae Most commonly involve the mitral valve (any valve can be involved) Most commonly found in the valve recess between the ventricular wall and the posterior leaflet Can involve the surface of the valves, valve ring, commissures.
Pathogenesis of Libman-Sacks endocarditis—proposed mechanisms Fibrin and platelet thrombi on the impaired valves-- organization leads to fibrosis, distortion, and subsequent valvular dysfunction Immunologic injury--initial insult to the valvular apparatus, triggering the sequence of pathogenetic events. Deposits of immunoglobulins and complement were shown in the subendothelial layer of the valves in patients with antiphospholipid antibodies
Verrucous endocarditis--Continued Typically asymptomatic Verrucae can fragment and produce systemic emboli, and infective endocarditis can develop on already damaged valves Blood cultures and echocardiography should be performed whenever fever and a new murmur are noted in a patient with SLE Antibiotic prophylaxis for patients with SLE undergoing procedures associated with a risk of developing bacteremia (such as dental care) in view of the high frequency of valvular disease
Verrucous endocarditis- Therapy Corticosteroid and/or cytotoxic therapy have no effect upon valvular lesions steroids may facilitate healing of valvular vegetations, which may result in marked scarring and deformity of the valve, thereby most likely leading to valve dysfunction Anticoagulation treatment should be considered for those patients with vegetations. Valve replacement surgery or valvuloplasty may be necessary for some patients who develop severe mitral or aortic valvular insufficiency, or, rarely for those with symptomatic stenotic lesions.
Echocardiographic appearance Usually less than 1 square centimeter in size Irregular margins Heterogeneous echodensity Do not exhibit independent motion Most valves with masses have associated thickening or regurgitation
The verrucae are usually near the edge of the valve and consist of accumulations of immune complexes, mononuclear cells, hematoxylin bodies, and fibrin and platelet thrombi
Differential diagnosis of a valvular mass/valve thickening Infective endocarditis Oscillating mass independent of leaflet motion Pseudoinfective endocarditis Clinical syndrome of active SLE that mimics IE, thus presenting a diagnostic and therapeutic dilemma Leukopenia Elevated aPL antibodies Negative or low positive CRP Repeatedly negative blood cultures
Differential diagnosis of a valvular mass/valve thickening Nonbacterial thrombotic endocarditis Sterile platelet and fibrin thrombi on cardiac valves and adjacent endocardium Response to trauma, local turbulence, circulating immune complexes, vasculitis, and hypercoagulable states Valvular thrombotic lesions that produce significant emboli (cerebral, visceral, coronary) NBTE uniformly have multiple, widely distributed, small and large strokes Observed in patients with chronic wasting disease, DIC, autoimmune diseases, mucin-producing metastatic carcinomas, chronic infections
Differential diagnosis of a valvular mass/valve thickening Age-related valve degeneration Annular calcification/sclerosis Myxomatous changes Rheumatic valvular disease Leaflet thickening confined to the leaflet tips Chordal involvement—thickening, fusion, calcification
Differential diagnosis of a valvular mass/valve thickening Lambl’s excresences Found in 70-85% of adult heart valves; usually multiple Usually arise from line of closure of the valves Do not appear to be a primary source of embolism (rarely), and do not change in appearance over time Usually do not occur on the arterial side of the semilunar valves or on the mural endocardium
Differential diagnosis of a valvular mass/valve thickening Papillary fibroelastoma Most common primary cardiac valve tumor Has typical morphology—mass composed of papillary fronds and a stalk that connects it to the endocardium Usually solitary and <1.0 cm in diameter Occur most frequently on the mid portion of the body of the valve leaflet May present with neurologic symptoms (embolism from fragments of tumor or adherent thrombus) or coronary involvement (embolism, obstruction of coronary ostium) Surgical resection recommended even if asymptomatic
Antiphospholipid (aPL) Syndrome Characterized by recurrent venous and arterial thrombosis as well as recurrent fetal (1 st and 2 nd trimester) loss and thrombocytopenia. Must demonstrate presence of aPL antibodies: Anticardiolipin Lupus anticoagulant
Criteria for Antiphospholipid Syndrome Clinical criteria Vascular thrombosis Pregnancy morbidity Unexplained fetal death beyond 10wks Premature birth before 34wks 3 or more unexplained spontaneous abortions before 10wks Lab criteria aCL-IgG or IgM in moderate or high titer 2x over 6 weeks LA on 2 occasions at least 6 weeks apart Adapted from Sapporo Conference, 1999 APS is present if at least 1 clinical and 1 lab criteria are met.
Is the cardiac valve disease of APS inflammatory or thrombotic? Histologic studies suggest that fibrin deposits are the major findings, not inflammation. However, subendothelial antibody deposition and complement components initiating valve damage have been described, along with increased endothelial cell expression of α3β1 integrin. Afek et al. Lupus. 1999;8: One case report suggested that anticoagulation caused disappearance of valve vegetations. Skyrme-Jones A et al J Am Soc Echo. 1995; 8:
5 year follow up study of Espinola-Zavaleta, et al Highly selected population of patients with primary APS Predominant cardiac lesion was a noninfective valve lesion. Oral anticoagulant treatment and aspirin proved ineffective in terms of valvular lesion regression. Myocardial infarction occurred in 9 (37.5%) patients. All had coronary angiography and coronary arteries were normal in 6. J Rheumatol 2004;31:2402-7
Antiphospholipid syndrome (APS) related valvulopathy Four patients reported to have “dramatic clinical and hemodynamic response” to treatment with prednisone when symptomatic measures failed Hence, pathogenisis of valvulopathy may involve interaction of aPL with antigens on the valve surface, resulting in valvulitis Nesher G., et al. Semin Arthritis Rheum Aug;27(1):27-35.
Conclusions SLE is a complex disease with protean cardiac manifestations (“pancarditis” etc) Prevalence of valvular disease in the setting of SLE (+/- aPL) is likely underestimated as the valvular involvement is usually of minimal hemodynamic significance and clinically silent. The simultaneous presence of SLE and aPL in the setting of valvular disease presents a diagnostic conundrum. Both entities are independently associated with valvular disease and contribute to a greater likelihood of embolic events.
More conclusions There is substantial morbidity associated with valvular involvement in SLE, especially with concomitant aPL. Further basic and clinical investigation in this area is imperative to help elucidate the natural history of this disease so that we can provide more effective, evidence- based therapies and assist in preventing some of the its adverse sequelae.