Libman-Sacks Endocarditis Involving a Bioprosthesis in the Aortic Valve Position in Systemic Lupus Erythematosus

Multiple organ dysfunction after mitral valve replacement in a patient with systemic lupus erythematosus complicated by Libman-Sacks endocarditis: a case report and literature review

This case report describes a 47-year-old woman with systemic lupus erythematosus (SLE) complicated by Libman-Sacks endocarditis (LSE) who developed multiple organ dysfunction after mitral valve replacement surgery. The patient presented with a 5-day history of cough, sputum, and fever. Transthoracic echocardiography showed significant vegetations on the mitral valve. Biopsy was performed, and the pathological diagnosis was SLE complicated by LSE. After the mitral valve replacement surgery, the patient developed clinical manifestations of hepatic and renal dysfunction, cardiopulmonary failure, oliguria, and shock. The clinical symptoms significantly improved after administration of mechanical ventilation, continuous renal replacement therapy, plasma exchange, anti-inflammatory and anti-infection treatments, immunomodulatory and immunosuppressive therapies, and low-molecular-weight heparin anticoagulation. Multiple organ dysfunction after mitral valve replacement in patients with SLE complicated by LSE has rarely been reported. This report discusses the clinical manifestations, pathogenesis, and treatment of this severe complication. We hope the sharing of our experience in this case will provide a clinical basis for the treatment of severe multiple organ dysfunction after mitral valve replacement in patients with SLE complicated by LSE.

[Libman-Sacks endocarditis under apixaban in a patient with a high-risk profile venous antiphospholipid syndrome]

INTRODUCTION

Libman-Sacks endocarditis is a rare complication of antiphospholipid syndrome. Anti-vitamin K therapy is the standard treatment, although valvular replacement surgery may be required in some severe cases. In the latest EULAR recommendations, it is advised not to use direct oral anticoagulants in the management of antiphospholipid syndrome, especially of high-risk profile.

CASE REPORT

We present a case of a mitral Libman-Sacks endocarditis complicated with multiple strokes occurring in the setting of an antiphospholipid syndrome with triple positive antibody profile in a 63-year-old woman with multiple sclerosis. She was previously treated with apixaban for two years. Tinzaparin followed by prolonged warfarine treatment and two months of hydroxychloroquine resulted in valvular improvement.

CONCLUSION

To our knowledge, this is the first case of Libman-Sacks endocarditis occurring during apixaban therapy in a patient with antiphospholipid syndrome. This severe case highlights the inefficiency of direct oral anticoagulants to prevent thrombotic events in the antiphospholipid syndrome.

A Tale of Two Valves: Bioprosthetic Aortic Valve Obstruction in Systemic Lupus Erythematosus and Antiphospholipid Antibody Syndrome

Patients with systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APLAS) are at risk for cardiac manifestations, specifically valvular heart disease requiring valve replacement. Bioprosthetic valve endocarditis is an important cause of valve failure, and it is important to keep a wide differential, especially in patients with preexisting SLE and APLAS. In this E-challenge, 2 cases of bioprosthetic aortic valve endocarditis are presented; 1 case describes infective bacterial endocarditis on an aortic prosthesis and the second describes a patient with SLE and APLAS who developed bioprosthetic valve obstruction secondary to vegetations, consistent with nonbacterial endocarditis and thrombus. Etiologies for bioprosthetic valve obstruction and evaluation by echocardiography are explored. The comparison between these 2 cases specifically highlights the importance of keeping a wide differential in endocarditis, prosthetic valve vegetations, and bioprosthetic valve obstruction.