eMedicine Specialties > Cardiology > Valvular Heart Disease

Libman-Sacks Endocarditis: Follow-up

Author: Xiushui (Mike) Ren, MD, Clinical Cardiology Fellow, Division of Cardiology, Kanbar Cardiac Center, California Pacific Medical Center
Coauthor(s): Elyse Foster, MD, Director of Adult Echocardiography Laboratory, Assistant Professor, Department of Internal Medicine, Division of Cardiology, Moffitt Hospital, University of California at San Francisco; Elizabeth W Ryan, MBBS, Consulting Staff, Department of Medicine, Division of Cardiology, Austin and Repatriation General Centre, Australia
Contributor Information and Disclosures

Updated: Sep 16, 2008

Follow-up

Further Inpatient Care

Hospitalization might be required for the following related to Libman-Sacks endocarditis:

  • Stabilization of heart failure
  • Heparinization, if immediate anticoagulation is required (eg, thromboembolism)
  • Cardiac surgery
  • Treatment of infective endocarditis
  • Evaluation of cerebral ischemia

Further Outpatient Care

Outpatient management issues might include the following:

  • Monitoring of anticoagulation
  • Adjustment of heart failure medication and monitoring of fluid status, renal function, and electrolytes
  • Antibiotic prophylaxis for dental work and procedures
  • Monitoring of underlying systemic lupus erythematosus disease activity with adjustments of steroids

Transfer

Cardiac surgery in patients with systemic lupus erythematosus carries a relatively higher risk of complications. Transfer to a tertiary care facility for valve replacement might be warranted in some cases.

Complications

  • Complications secondary to Libman-Sacks endocarditis are uncommon.
  • Valvular regurgitation and, rarely, stenosis might result in heart failure and arrhythmias, such as atrial fibrillation. See Medscape's Atrial Fibrillation Resource Center.
  • Systemic emboli rarely occur as a result of valvular lesions. The risk is increased substantially in the presence of mitral stenosis, atrial fibrillation, or both.
  • Secondary infective endocarditis is thought to be rare.

Prognosis

  • Longitudinal data of valvular abnormalities are limited. Two series report no progression of mild or moderate regurgitation to severe regurgitation over a 2- to 3-year period and report only isolated cases of mildly progressive stenosis.
  • Prognosis is probably dependent on the underlying disease activity of systemic lupus erythematosus and associated renal and myocardial dysfunction.

Patient Education

  • Give patients on anticoagulation written information regarding potential drug interactions, dietary advice, the need for regular monitoring of the international normalized ratio, and warning symptoms of hemorrhage.
  • Referral to an anticoagulation clinic might be appropriate.
  • Educate patients about the need for antibiotic prophylaxis in case of lacerations, dental work, and other procedures.
  • Information regarding systemic lupus erythematosus is available through the following Web sites:
  • For excellent patient education resources, see eMedicine's patient education article Lupus (Systemic Lupus Erythematosus).

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider an underlying condition, such as systemic lupus erythematosus or antiphospholipid antibody syndrome
  • Failure to consider an infective etiology of valvular vegetations
  • Failure to administer antibiotic prophylaxis for procedures and dental work (in patients with known valvular abnormalities)
  • Misdiagnosis as infective endocarditis, with inappropriate course of antibiotic therapy or cardiac surgery
  • Failure to recognize associated pulmonary hypertension due to pulmonary pathology when evaluating the severity of valvular dysfunction

Special Concerns

Pregnancy raises several areas of concern relating to the treatment of complications of Libman-Sacks endocarditis and its associated conditions.

  • Anticoagulation with warfarin during the first trimester might result in fetal abnormalities.
  • Warfarin therapy during the third trimester increases the risk of hemorrhage with delivery. However, alternative anticoagulants and antiplatelet agents are not without risk and might not be as efficacious. Individualize case management.
  • Maternal valvular dysfunction might decompensate, resulting in heart failure with increased risks to the mother and fetus.
  • Avoid ACE inhibitors.
  • Maternal systemic lupus erythematosus with anti-Ro/SS-A (Sjögren syndrome antigen A) autoantibodies is associated with fetal heart block.
  • The risk of spontaneous miscarriage is increased in patients with antiphospholipid syndrome.
  • Do not administer tetracycline-based antibiotics.

 


More on Libman-Sacks Endocarditis

Overview: Libman-Sacks Endocarditis
Differential Diagnoses & Workup: Libman-Sacks Endocarditis
Treatment & Medication: Libman-Sacks Endocarditis
Follow-up: Libman-Sacks Endocarditis
Multimedia: Libman-Sacks Endocarditis
References
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References

  1. Libman E, Sacks B. A hitherto undescribed form of valvular and mural endocarditis. Arch Intern Med. 1924;33:701-37.

  2. Moyssakis I, Tektonidou MG, Vasilliou VA, Samarkos M, Votteas V, Moutsopoulos HM. Libman-Sacks endocarditis in systemic lupus erythematosus: prevalence, associations, and evolution. Am J Med. July 2007;120:636-42. [Medline]. [Full Text].

  3. Nighoghossian N, Trouillas P, Perinetti M, Barthelet M, Ninet J, Loire R. [Lambl's excrescence: an uncommon cause of cerebral embolism]. Rev Neurol (Paris). Oct 1995;151(10):583-5. [Medline].

  4. Roldan CA, Qualls CR, Sopko KS, Sibbitt WL Jr. Transthoracic versus transesophageal echocardiography for detection of Libman-Sacks endocarditis: a randomized controlled study. J Rheumatol. February 2008;35:224-9. [Medline]. [Full Text].

  5. Aziz F, Baciewicz FA Jr. Lambl's excrescences: review and recommendations. Tex Heart Inst J. 2007;34(3):366-8. [Medline].

  6. Brenner B, Blumenfeld Z, Markiewicz W, Reisner SA. Cardiac involvement in patients with primary antiphospholipid syndrome. J Am Coll Cardiol. Oct 1991;18(4):931-6. [Medline].

  7. Bulkley BH, Roberts WC. The heart in systemic lupus erythematosus and the changes induced in it by corticosteroid therapy. A study of 36 necropsy patients. Am J Med. Feb 1975;58(2):243-64. [Medline].

  8. Cervera R, Font J, Pare C, et al. Cardiac disease in systemic lupus erythematosus: prospective study of 70 patients. Ann Rheum Dis. Feb 1992;51(2):156-9. [Medline].

  9. Dajee H, Hurley EJ, Szarnicki RJ. Cardiac valve replacement in systemic lupus erythematosus. A review. J Thorac Cardiovasc Surg. May 1983;85(5):718-26. [Medline].

  10. Fitzgerald D, Gaffney P, Dervan P, Doyle CT, Horgan J, Nelligan M. Giant Lambl's excrescence presenting as a peripheral embolus. Chest. Apr 1982;81(4):516-7. [Medline].

  11. Galve E, Candell-Riera J, Pigrau C, et al. Prevalence, morphologic types, and evolution of cardiac valvular disease in systemic lupus erythematosus. N Engl J Med. Sep 29 1988;319(13):817-23. [Medline].

  12. Gleason CB, Stoddard MF, Wagner SG, et al. A comparison of cardiac valvular involvement in the primary antiphospholipid syndrome versus anticardiolipin-negative systemic lupus erythematosus. Am Heart J. Apr 1993;125(4):1123-9. [Medline].

  13. Hojnik M, George J, Ziporen L, Shoenfeld Y. Heart valve involvement (Libman-Sacks endocarditis) in the antiphospholipid syndrome. Circulation. Apr 15 1996;93(8):1579-87. [Medline].

  14. Khamashta MA, Cervera R, Asherson RA, et al. Association of antibodies against phospholipids with heart valve disease in systemic lupus erythematosus. Lancet. Jun 30 1990;335(8705):1541-4. [Medline].

  15. Leung WH, Wong KL, Lau CP, et al. Association between antiphospholipid antibodies and cardiac abnormalities in patients with systemic lupus erythematosus. Am J Med. Oct 1990;89(4):411-9. [Medline].

  16. Moder KG, Miller TD, Tazelaar HD. Cardiac involvement in systemic lupus erythematosus. Mayo Clin Proc. 1999;74:275-84. [Medline].

  17. Morin AM, Boyer AS, Nataf P, Gandjbakhch I. Mitral insufficiency caused by systemic lupus erythematosus requiring valve replacement: three case reports and a review of the literature. Thorac Cardiovasc Surg. Dec 1996;44(6):313-6. [Medline].

  18. Nihoyannopoulos P, Gomez PM, Joshi J, et al. Cardiac abnormalities in systemic lupus erythematosus. Association with raised anticardiolipin antibodies. Circulation. Aug 1990;82(2):369-75. [Medline].

  19. O'Neill D, Magaldi J, Dobkins D, Greco T. Dissolution of intracardiac mass lesions in the primary antiphospholipid antibody syndrome. Arch Intern Med. Feb 13 1995;155(3):325-7. [Medline].

  20. Roldan CA. Valvular disease associated with systemic illness. Cardiol Clin. Aug 1998;16(3):531-50. [Medline].

  21. Roldan CA, Shively BK, Crawford MH. An echocardiographic study of valvular heart disease associated with systemic lupus erythematosus. N Engl J Med. Nov 7 1996;335(19):1424-30. [Medline].

  22. Roldan CA, Shively BK, Lau CC, et al. Systemic lupus erythematosus valve disease by transesophageal echocardiography and the role of antiphospholipid antibodies. J Am Coll Cardiol. Nov 1 1992;20(5):1127-34. [Medline].

  23. Skyrme-Jones RA, Wardrop CA, Wiles CM, Fraser AG. Transesophageal echocardiographic demonstration of resolution of mitral vegetations after warfarin in a patient with the primary antiphospholipid syndrome. J Am Soc Echocardiogr. May-Jun 1995;8(3):251-6. [Medline].

  24. Turiel M, Sarzi-Puttini P, Peretti R, Bonizzato S, Muzzupappa S, Atzeni F, et al. Five-year follow-up by transesophageal echocardiographic studies in primary antiphospholipid syndrome. Am J Cardiol. Aug 15 2005;96(4):574-9. [Medline].

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Further Reading

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Keywords

Libman-Sacks endocarditis, endocarditis, nonbacterial verrucous endocarditis, systemic lupus erythematosus, SLE, autoimmune disease, cardiac manifestations of autoimmune disease, verrucous vegetations, Libman-Sacks vegetations, heart valve abnormality, primary antiphospholipid syndrome, antiphospholipid syndrome, cardiac failure, cardiac vegetations

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Contributor Information and Disclosures

Author

Xiushui (Mike) Ren, MD, Clinical Cardiology Fellow, Division of Cardiology, Kanbar Cardiac Center, California Pacific Medical Center
Xiushui (Mike) Ren, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, and American Society of Echocardiography
Disclosure: Nothing to disclose.

Coauthor(s)

Elyse Foster, MD, Director of Adult Echocardiography Laboratory, Assistant Professor, Department of Internal Medicine, Division of Cardiology, Moffitt Hospital, University of California at San Francisco
Elyse Foster, MD is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Heart Association, and American Society of Echocardiography
Disclosure: Nothing to disclose.

Elizabeth W Ryan, MBBS, Consulting Staff, Department of Medicine, Division of Cardiology, Austin and Repatriation General Centre, Australia
Elizabeth W Ryan, MBBS is a member of the following medical societies: American College of Cardiology and American Heart Association
Disclosure: Nothing to disclose.

Medical Editor

Craig T Basson, MD, PhD, FAHA, FACC, Director, Cardiovascular Research, The New York Presbyterian Hospital; Professor, Greenberg Division of Cardiology, Department of Medicine, Weill Medical College of Cornell University
Craig T Basson, MD, PhD, FAHA, FACC is a member of the following medical societies: American College of Cardiology and American Heart Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Frank M Sheridan, MD, Cardiology, Providence Everett Medical Center
Frank M Sheridan, MD is a member of the following medical societies: American College of Cardiology, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Patrice Delafontaine, MD, FACC, FAHA, FACP, FESC, Sidney W and Marilyn S Lassen Professor of Cardiovascular Medicine, Chief, Section of Cardiology, Director, Cardiovascular Center of Excellence, Tulane University; Professor of Physiology, Chair, Department of Medicine, Tulane University School of Medicine
Patrice Delafontaine, MD, FACC, FAHA, FACP, FESC is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American College of Cardiology, American College of Physicians, American Diabetes Association, American Federation for Clinical Research, American Federation for Medical Research, American Heart Association, American Medical Association, American Society for Clinical Investigation, Association of American Physicians, Association of Professors of Cardiology, Association of Professors of Medicine, Endocrine Society, European Society of Cardiology, Louisiana State Medical Society, and Southern Society for Clinical Investigation
Disclosure: Nothing to disclose.

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