Libman–Sacks endocarditis

Specialty| Rheumatology, Cardiology
Symptoms| Nonbacterial thrombotic endocarditis, Marantic endocarditis, verrucous endocarditis
Causes| Systemic lupus erythematosus,
Malignancy,
Antiphospholipid syndrome
Diagnostic method| Echocardiography

Libman–Sacks endocarditis is a form of non-bacterial endocarditis that is seen in association with systemic lupus erythematosus, antiphospholipid syndrome, and malignancies. It is one of the most common cardiac manifestations of lupus (the most common being pericarditis).[1][2]

## Contents

* 1 Presentation
* 1.1 Complications
* 1.1.1 Emboli
* 2 Causes
* 2.1 Systemic lupus erythematosus
* 3 Pathophysiology
* 3.1 Histopathology
* 4 Diagnosis
* 4.1 Echocardiography
* 4.2 Differential diagnosis
* 5 Management/treament
* 6 Prognosis
* 7 Epidemiology
* 8 History
* 9 References
* 10 External links

## Presentation

Libman–Sacks endocarditis itself is typically asymptomatic. Affected persons most commonly present with embolisms secondary to dislodged vegetations. However, in some cases, severe valvular dysfunction may develop. People with systemic lupus erythematosus may present with other symptoms of the underlying diseases that give rise to Libman–Sacks endocarditis. [3]

### Complications

Libman–Sacks endocarditis may result in arterial emboli, valvular insufficiency, and heart failure. Infective endocarditis occurs more frequently with those with systemic lupus erythematosus.[4]

#### Emboli

Vegetations occurring in the context of Libman–Sacks endocarditis may dislodge to form emboli and cause embolism (including cerebral embolism (presenting as stroke or transient ischaemic attack), mesenteric ischaemia (presenting with severe abdominal pain), or peripheral arterial embolism (presenting with limb coldness)).[2]

## Causes

Libman–Sacks endocarditis occurs in association with systemic lupus erythematosus, antiphospholipid syndrome, and malignancies.[2]

### Systemic lupus erythematosus

In systemic lupus erythematosus, Libman–Sacks endocarditis has been linked to pericarditis, presence of anticardiolipin antibodies, arterial and venous thromboses, and neuropsychiatric manifestations of systemic lupus erythematosus. Libman–Sacks endocarditis is associated with greater systemic lupus erythematosus duration and severity. In some cases, Libman–Sacks endocarditis may be the presenting pathology in systemic lupus erythematosus, especially in the presence of concurrent antiphospholipid syndrome.[4]

## Pathophysiology

The initial cause of Libman–Sacks endocarditis is poorly understood. It is thought to occur in the context of a hypercoagulable state which leads to endothelial injury and subsequent deposition of thrombi and inflammatory molecules in affected valves. The vegetations that are thus formed consist of immune complexes, platelet thrombi, fibrin, and mononuclear cells. The vegetations may dislodge and cause embolisms.[2]

### Histopathology

Libman–Sacks endocarditis involves formation of cardiac lesions that may take the form of vegetations or thickening of the valvular leaflets.[4][2]

The vegetations are small and formed from strands of fibrin, neutrophils, lymphocytes, and histiocytes.[5] Vegetations are most often small-to-moderate in size (up to 10 mm),[4] but may sometimes be large (larger than 10 mm).[2] The mitral valve is typically affected, and the vegetations occur on the ventricular and atrial surface of the valve.[5] Though the left-sided heart valves (mitral and aortic) are most commonly affected, any heart valve as well as adjoining structures may become involved.[4]

Libman–Sacks lesions rarely produce significant valve dysfunction and the lesions only rarely embolize.[5] However, there is data to suggest an association between Libman–Sacks endocarditis and a higher risk for embolic cerebrovascular disease in people with systemic lupus erythematosus.[3]

## Diagnosis

Libman–Sacks endocarditis should be considered in instances of thromboembolism in persons with underlying pathology that is associated with LSE. Libman–Sacks endocarditis is diagnosed with echocardiography. Other potential etiologies (e.g. infective endocarditis) should be excluded through an extensive assessment (complete blood count and metabolic panel, blood cultures). Libman–Sacks endocarditis can also be identified post-mortem during an autopsy.[2]

### Echocardiography

Echocardiography is considered the primary evaluation for Libman–Sacks endocarditis; transesophageal echocardiography has greater sensitivity and specificity than transthoracic echocardiography.[2][4] In case of a negative TTE in the presence of clinical signs of Libman–Sacks endocarditis, transesophageal echocardiography may be attempted to confirm the presence of the condition.[4]

Vegetations of the cardiac valves and endocardium are characterised by irregular borders, heterogenous echo density, and an absence of independent motion. Vegetations are usually small, but may be as large as 10mm. The basal and middle portions of the mitral and aortic valves are most commonly involved. Leaflet thickening or regurgitation may be present. There may be other cardiac pathology related to the underlying cause, e.g., lupus.[2]

### Differential diagnosis

Differential diagnoses include: rheumatic valvular disease, atrial myxoma, degenerative valvular disease, infective endocarditis, vasculitis, cholesterol emboli syndrome, fibroelastoma, and Lambl's excrescences.[2]

## Management/treament

The condition should be monitored to follow the development of the vegetations, and health personnel should be conscious of the potential risks associated with the condition.[2]

There is a paucity of empirical evidence on treatment options for persons with Libman–Sacks endocarditis, and treatment should focus on the underlying cause. Anticoagulant treatment is recommended in cases with previous thromboembolic event for prevention of subsequent occurrences. Surgical intervention may be indicated in case of significant valvular dysfunction.[2]

## Prognosis

Libman–Sacks endocarditis is often associated with considerable morbidity and mortality.[2]

## Epidemiology

Libman–Sacks endocarditis has been observed in 0.2% in of the general population at autopsy. It occurs most commonly in those aged 40 to 80 years.[2]

Libman–Sacks endocarditis vegetations are observed in 10% of systemic lupus erythematosus cases (however, in one study, vegetations were noted in 43% of systemic lupus erythematosus cases (0% in controls), and valvular thickening in 51% of systemic lupus erythematosus cases (7% in controls)[4]).[2] There is a significant correlation between systemic lupus erythematosus duration and severity, and the incidence of Libman–Sacks endocarditis.[2][4] Libman–Sacks endocarditis has been identified in 1.25% of those with malignant disease at autopsy.[2]

## History

It was first described by Emanuel Libman and Benjamin Sacks at Mount Sinai Hospital in New York City in 1924.[6][7] The association between Libman–Sacks endocarditis and antiphospholipid syndrome was first noted in 1985.[8]

## References

1. ↑ "Libman–Sacks endocarditis". Mosby's Medical, Nursing & Allied Health Dictionary (Fourth ed.). Mosby-YearBook. 1994. p. 907.
2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 Ibrahim, Abdisamad M.; Siddique, Momin S. (2020), "Libman Sacks Endocarditis", StatPearls (StatPearls Publishing), PMID 30422459, http://www.ncbi.nlm.nih.gov/books/NBK532864/, retrieved 2020-05-30
3. ↑ 3.0 3.1 Roldan, C. A.; Sibbitt, W. L. Jr (2013). "Libman–Sacks endocarditis and embolic cerebrovascular disease". Cardiovascular Imaging 6 (9): 973–983. doi:10.1016/j.jcmg.2013.04.012. PMID 24029368.
4. ↑ 4.0 4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8 Wallace, Daniel J.; Hahn, Bevra (16 August 2018). Dubois' lupus erythematosus and related syndromes (Ninth ed.). Edinburgh. ISBN 978-0-323-55064-2. OCLC 1051140253.
5. ↑ 5.0 5.1 5.2 Doherty, N. E.; Siegel, R. J. (1985). "Cardiovascular manifestations of systemic lupus erythematosus". American Heart Journal 110 (6): 1257–1265. doi:10.1016/0002-8703(85)90023-7. PMID 3907317.
6. ↑ Libman, E.; Sacks, B. (1924). "A hitherto undescribed form of valvular and mural endocarditis". Archives of Internal Medicine 33 (6): 701–737. doi:10.1001/archinte.1924.00110300044002.
7. ↑ "Patient.info: Libman–Sacks Endocarditis". http://patient.info/doctor/libman-sacks-endocarditis.
8. ↑ Hojnik Maja; George Jacob; Ziporen Lea; Shoenfeld Yehuda (1996-04-15). "Heart Valve Involvement (Libman-Sacks Endocarditis) in the Antiphospholipid Syndrome". Circulation 93 (8): 1579–1587. doi:10.1161/01.CIR.93.8.1579. PMID 8608627.

## External links

Classification|

* ICD-10: I39, M32.1
* ICD-9-CM: 710.0
* MeSH: D008180
* DiseasesDB: 29254

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External resources|

* eMedicine: med/1295

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* e

Cardiovascular disease (heart) (I00–I52, 390–429)

Ischaemic|

| Coronary disease|

* Coronary artery disease (CAD)
* Coronary artery aneurysm
* Spontaneous coronary artery dissection (SCAD)
* Coronary thrombosis
* Coronary vasospasm
* Myocardial bridge

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Active ischemia|

* Angina pectoris
* Prinzmetal's angina
* Stable angina
* Acute coronary syndrome
* Myocardial infarction
* Unstable angina

Sequelae|

* hours
* Hibernating myocardium
* Myocardial stunning
* days
* Myocardial rupture
* weeks
* Aneurysm of heart / Ventricular aneurysm
* Dressler syndrome

Layers|

| Pericardium|

* Pericarditis
* Acute
* Chronic / Constrictive
* Pericardial effusion
* Cardiac tamponade
* Hemopericardium

|

Myocardium|

* Myocarditis
* Chagas disease
* Cardiomyopathy
* Dilated
* Alcoholic
* Hypertrophic
* Tachycardia-induced
* Restrictive
* Loeffler endocarditis
* Cardiac amyloidosis
* Endocardial fibroelastosis
* Arrhythmogenic right ventricular dysplasia

Endocardium /
valves|

| Endocarditis|

* infective endocarditis
* Subacute bacterial endocarditis
* non-infective endocarditis
* Libman–Sacks endocarditis
* Nonbacterial thrombotic endocarditis

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Valves|

* mitral
* regurgitation
* prolapse
* stenosis
* aortic
* stenosis
* insufficiency
* tricuspid
* stenosis
* insufficiency
* pulmonary
* stenosis
* insufficiency

Conduction /
arrhythmia|

| Bradycardia|

* Sinus bradycardia
* Sick sinus syndrome
* Heart block: Sinoatrial
* AV
* 1°
* 2°
* 3°
* Intraventricular
* Bundle branch block
* Right
* Left
* Left anterior fascicle
* Left posterior fascicle
* Bifascicular
* Trifascicular
* Adams–Stokes syndrome

|

Tachycardia
(paroxysmal and sinus)|

| Supraventricular|

* Atrial
* Multifocal
* Junctional
* AV nodal reentrant
* Junctional ectopic

|

Ventricular|

* Accelerated idioventricular rhythm
* Catecholaminergic polymorphic
* Torsades de pointes

Premature contraction|

* Atrial
* Junctional
* Ventricular

Pre-excitation syndrome|

* Lown–Ganong–Levine
* Wolff–Parkinson–White

Flutter / fibrillation|

* Atrial flutter
* Ventricular flutter
* Atrial fibrillation
* Familial
* Ventricular fibrillation

Pacemaker|

* Ectopic pacemaker / Ectopic beat
* Multifocal atrial tachycardia
* Pacemaker syndrome
* Parasystole
* Wandering atrial pacemaker

Long QT syndrome|

* Andersen–Tawil
* Jervell and Lange-Nielsen
* Romano–Ward

Cardiac arrest|

* Sudden cardiac death
* Asystole
* Pulseless electrical activity
* Sinoatrial arrest

Other / ungrouped|

* hexaxial reference system
* Right axis deviation
* Left axis deviation
* QT
* Short QT syndrome
* T
* T wave alternans
* ST
* Osborn wave
* ST elevation
* ST depression
* Strain pattern

Cardiomegaly|

* Ventricular hypertrophy
* Left
* Right / Cor pulmonale
* Atrial enlargement
* Left
* Right
* Athletic heart syndrome

Other|

* Cardiac fibrosis
* Heart failure
* Diastolic heart failure
* Cardiac asthma
* Rheumatic fever

* v
* t
* e

Systemic connective tissue disorders

General|

| Systemic lupus erythematosus|

* Drug-induced SLE
* Libman–Sacks endocarditis

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Inflammatory myopathy|

* Myositis
* Dermatopolymyositis
* Dermatomyositis/Juvenile dermatomyositis
* Polymyositis* Inclusion body myositis

Scleroderma|

* Systemic scleroderma
* Progressive systemic sclerosis
* CREST syndrome

* Overlap syndrome / Mixed connective tissue disease

Other hypersensitivity/autoimmune|

* Sjögren syndrome

Other|

* Behçet's disease
* Polymyalgia rheumatica
* Eosinophilic fasciitis
* Eosinophilia–myalgia syndrome
* fibrillin
* Marfan syndrome
* Congenital contractural arachnodactyly

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