Aortic valve incompetence and replacement in rheumatoid arthritis

Acute on chronic severe aortic insufficiency due to rheumatoid arthritis-associated valvulitis

Rheumatoid Arthritis associated valvular heart disease (RA-VHD) may occur in patients in varying degrees of severity. Aortic valve involvement leading to severe symptomatic aortic insufficiency is a rare complication of rheumatoid arthritis. This entity has not been well characterized and its clinical predictors are undefined. The pathology of RA-VHD can extend from benign nodular development to acute valvulitis with late-stage leaflet fibrosis and severe valvular regurgitation. In this report, we describe a rare case of acute heart failure (AHF) resulting from severe aortic valve destruction and insufficiency due to persistent chronic inflammation in a patient with long-standing RA. Persistent systemic inflammation of RA involved the aortic valve causing nodular thickening and leaflet destruction. Our patient had compensated chronic heart failure due to progressive aortic insufficiency resulting from gradual leaflet destruction. However, she suddenly developed AHF requiring valve replacement. Her clinical presentation, gross and histological images suggest an acute/subacute disruption of the friable aortic leaflets that resulted in AHF.

Long-Term Outcomes of Surgical Aortic Valve Replacement in Patients with Rheumatoid Arthritis

Background: Patients with rheumatoid arthritis (RA) have increased risk of developing cardiovascular disease and events. Little is, however, known about the influence of RA to the outcomes after surgical aortic valve replacement (SAVR). Methods: In a retrospective, nationwide, multicenter cohort study, RA patients (n = 109) were compared to patients without RA (n = 1090) treated with isolated SAVR for aortic valve stenosis. Propensity score-matching adjustment for baseline features was used to study the outcome differences in a median follow-up of 5.6 years. Results: Patients with RA had higher all-cause mortality (HR 1.76; CI 1.21–2.57; p = 0.003), higher incidence of major adverse cardiovascular events (HR 1.63; CI 1.06–2.49; p = 0.025), and they needed more often coronary artery revascularization for coronary artery disease (HR 3.96; CI 1.21–12.90; p = 0.027) in long-term follow-up after SAVR. As well, cardiovascular mortality rate was higher in patients with RA (35.7% vs. 23.4%, p = 0.023). There was no difference in 30-day mortality (2.8% vs. 1.8%, p = 0.518) or in the need for aortic valve reoperations (3.7% vs. 4.0%, p = 0.532). Conclusions: Patients with rheumatoid arthritis had impaired long-term results and increased cardiovascular mortality after SAVR for aortic valve stenosis. Special attention is needed to improve outcomes of aortic valve stenosis patients with RA after SAVR.

Cardiac phenotype in mouse models of systemic autoimmunity

Patients suffering from systemic autoimmune diseases are at significant risk of cardiovascular complications. This can be due to systemically increased levels of inflammation leading to accelerated atherosclerosis, or due to direct damage to the tissues and cells of the heart. Cardiac complications include an increased risk of myocardial infarction, myocarditis and dilated cardiomyopathy, valve disease, endothelial dysfunction, excessive fibrosis, and bona fide autoimmune-mediated tissue damage by autoantibodies or auto-reactive cells. There is, however, still a considerable need to better understand how to diagnose and treat cardiac complications in autoimmune patients. A range of inducible and spontaneous mouse models of systemic autoimmune diseases is available for mechanistic and therapeutic studies. For this Review, we systematically collated information on the cardiac phenotype in the most common inducible, spontaneous and engineered mouse models of systemic lupus erythematosus, rheumatoid arthritis and systemic sclerosis. We also highlight selected lesser-known models of interest to provide researchers with a decision framework to choose the most suitable model for their study of heart involvement in systemic autoimmunity.

A clinico-pathological conference on constrictive pericarditis secondary to rheumatoid arthritis: a case report with expert commentary and review of the literature

Constrictive pericarditis is the commonest cardiac complication of rheumatoid arthritis (RA). Two percent of patients with RA develop significant clinical symptoms of pericarditis, which may not correlate with joint disease duration or severity. Symptoms are often vague and non-specific, which frequently delays the diagnosis and subsequent management. Surgical excision of the pericardium is the only definitive treatment option. We present the case of a 60 year-old lady with RA who presented with symptoms due to pericardial constriction and underwent radical pericardectomy.

Left-sided cardiac valvulitis in tristetraprolin-deficient mice: the role of tumor necrosis factor alpha

Inflammation may play a role in the etiology of both degenerative and rheumatic cardiac valve diseases. We report here that mice deficient in tristetraprolin (TTP), a protein with known anti-inflammatory functions, develop severe left-sided cardiac valvulitis. TTP is an mRNA binding protein that inhibits inflammation by destabilizing the mRNA encoding tumor necrosis factor alpha (TNF). This leads in turn to a TNF-excess syndrome characterized by systemic inflammation. Evaluation of hearts from TTP-/- mice demonstrated gross thickening of the mitral and aortic but not the tricuspid or pulmonary valves, accompanied by inflammatory cell infiltrates. To determine whether TNF played a role in the development of this valvulitis, we examined mice deficient in both TNF receptors and in TTP; four of five of these mice exhibited no histological evidence of valvulitis, but one mouse had aortic valve leaflet thickening with a cellular infiltrate. Four additional mice had no external evidence of valvular thickening. Cardiac valves of transgenic mice expressing human TNF developed mild aortic valve leaflet edema without evidence of hypercellularity. Thus, TTP deficiency in mice leads to left-sided cardiac valvulitis with prominent inflammatory cell involvement, due, at least in part, to excess TNF. These findings support the potential involvement of TNF and inflammation in the development of cardiac valve disease in man.

Characterization of valvular heart disease in rheumatoid arthritis by transesophageal echocardiography and clinical correlates

Valvular heart disease (VHD) associated with rheumatoid arthritis (RA) has not been well characterized and its clinical predictors are undefined. Therefore, 34 volunteers with RA with a mean age of 50 +/- 10 years underwent clinical evaluation and transesophageal echocardiography. Findings on transesophageal echocardiography were compared with those of 34 gender-matched healthy volunteers with a mean age of 42 +/- 6 years. Twenty patients (59%) had mainly (97%) left-sided VHD (valve nodules in 11, 32%; valve thickening in 18, 53%; valve regurgitation in 7, 21%; and valve stenosis in 1, 3%) compared with 5 controls (15%; [nodules in 1, 3%; thickening in 4, 12%; and regurgitation in 1, 3%; p < or =0.05 for all vs patients). Valve nodules were generally single and small (4 to 12 mm); were oval with regular borders and had homogenous echocardiographic reflectance; were typically located at the leaflets' basal or mid portions; and equally affected the aortic and mitral valves. Valve thickening was equally diffuse or localized; when localized affected any leaflet portion; was usually mild (89%); involved similarly the mitral and aortic valves (47% and 32%, respectively); and rarely (6%) involved the annulus and subvalvular apparatus. Valve regurgitation manifested as mild aortic regurgitation in 4 patients, moderate mitral regurgitation in 4 patients, and moderate tricuspid regurgitation in 1 patient. Mitral and aortic valve stenoses occurred in 1 patient (3%). No correlation was found between VHD and duration, activity, severity, pattern of onset and course, extra-articular disease, serology, or therapy of RA. In conclusion, RA-associated VHD is common, valve nodules and thickening are its distinctive features, and it is not associated with clinical variables of RA.

Severe rheumatoid valvular heart disease

Rheumatoid arthritis (RA) is a systemic inflammatory disease in which extra-articular involvement is not uncommon. Cardiac compromise may be frequent, although most often, it is clinically silent. Herein, two cases of RA-related endocarditis, one of which required valve replacement, are described. Etanercept was useful in controlling the articular and extra-articular RA compromise in both cases.

Myocardial dysfunction in rheumatoid arthritis: epidemiology and pathogenesis

Data from population- and clinic-based epidemiologic studies of rheumatoid arthritis patients suggest that individuals with rheumatoid arthritis are at risk for developing clinically evident congestive heart failure. Many established risk factors for congestive heart failure are over-represented in rheumatoid arthritis and likely account for some of the increased risk observed. In particular, data from animal models of cytokine-induced congestive heart failure have implicated the same inflammatory cytokines produced in abundance by rheumatoid synovium as the driving force behind maladaptive processes in the myocardium leading to congestive heart failure. At present, however, the direct effects of inflammatory cytokines (and rheumatoid arthritis therapies) on the myocardia of rheumatoid arthritis patients are incompletely understood.

Stentless Bioprosthetic Aortic Valve Replacement After a Homograft Root Replacement: Toronto SPV Implantation After a Homograft Root

Stentless bioprosthetic valves for the aortic position offer excellent hemodynamic characteristics, making them an attractive choice ahead of other valve prostheses. We present a unique case in which a patient underwent aortic valve replacement with a stentless porcine valve and mitral valve repair for severe aortic and mitral regurgitation 1 year after a homograft root replacement for acute aortic endocarditis. The rationale for our approach is outlined in the context of current surgical trends.

Cardiac manifestations of rheumatoid arthritis: a case-control transesophageal echocardiography study in 30 patients

OBJECTIVES

Current knowledge of the cardiac manifestations of rheumatoid arthritis (RA) stems only from clinical and transthoracic echocardiography (TTE) studies. To determine the incidence and type of heart lesions in RA, we coupled TTE with transesophageal echocardiography (TEE), which is more sensitive and more accurate.

METHODS

Thirty unselected RA patients (26 women and 4 men aged 27 to 84 years, with a mean age of 57.8+/-15.1 years) free of known progressive heart disease underwent a chest radiograph, an electrocardiogram, laboratory tests, and TTE coupled with TEE. Results were compared with those in age- and sex-matched patients who were free of rheumatic disease and who underwent TEE to investigate a neurologic or cardiologic disorder.

RESULTS

Mitral regurgitation (MR) was evidenced in 24 cases (80%). Among the controls, only 11 (37%) had MR (P < 0.001). Aortic regurgitation was found in 10 cases (33%), versus 7 controls (not significant-NS). Seven cases (23%) versus only 2 controls (7%) had tricuspid valve abnormalities (NS). Pericarditis was found in 4 cases (13%) and in none of the controls. Eleven cases had evidence of cardiomyopathy (37%) and 12 (40%) had atheroma of the aorta, this last being missed by TTE in 10 patients. Echo-generating nodules were seen on a mitral valve in 2 cases and on an aortic valve in 1. We found no correlations linking cardiac lesions to clinical or laboratory features of RA.

CONCLUSION

Our study demonstrated that cardiac involvement, particularly of the mitral valve, is extremely common in RA patients.

Heart valve disease in seronegative rheumatoid arthritis

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Cardiac compression in rheumatoid pericarditis

Rheumatoid pericarditis occurs in approximately one third of rheumatoid arthritis (RA) patients. However, clinically apparent rheumatoid pericarditis is infrequent. The authors found clinical pericarditis in 12 of 960 patients admitted for RA, 5 of whom had manifestations of cardiac compression. These 5 had longer duration of RA, worse functional class, and more extraarticular features than the patients without cardiac compression. Presenting features of cardiac compression included dyspnea, edema, chest pain, and pulsus paradoxus. Treatment of patients with cardiac compression due to rheumatoid pericarditis may include a trial of systemically administered corticosteroids, but this should not delay surgical intervention for impending tamponade. Pericardiocentesis should only be performed as an emergency, life-saving procedure. It may be followed by intrapericardiac injection of corticosteroids, but this does not prevent recurrence. Longer-lasting benefit is obtained by surgical decompression. Two-year mortality in patients with cardiac compression was 100%. The literature on the subject is reviewed.

Constrictive pericarditis in rheumatoid arthritis

Constrictive pericarditis is an unusual complication of rheumatoid arthritis, and its development appears to be uninfluenced by second-line therapy. Five patients are described who developed the disease, with possibly two more. Medical treatment is ineffective: the treatment of choice is surgical, and the postoperative prognosis is good. The crude prevalence rate for the association is 0.64% for males and 0.06% for females.

Rheumatoid involvement of the aortic arch

The clinical course of rheumatoid arthritis may be complicated by cardiac involvement. Indeed, postmortem studies suggest rheumatoid involvement in up to 50% of pericardial, 5% of myocardial, and 60% of valvular specimens. Yet, in our search of the literature, we found only a single case report describing aortic valve replacement for rheumatoid valvulitis. This discrepancy may be related to the paucity of symptoms in this sedentary group of patients. A complete cardiac evaluation of patients with rheumatoid arthritis is recommended to select those with significant valvular involvement for timely surgical intervention prior to the development of irreversible left ventricular dysfunction. Two patients who benefitted from aortic valve replacement for rheumatoid valvular disease are presented.

Aortic regurgitation in seropositive juvenile arthritis

Seropositive juvenile chronic arthritis is a relatively uncommon form of childhood arthritis, but it often causes severe destruction of joints associated with considerable functional disability. During the last 7 years lone aortic regurgitation has been seen to develop in 4 such patients and pursue a particularly aggressive course. Sudden deterioration occurred in 2, 1 of whom required urgent aortic valve replacement and 1 died while awaiting assessment. Because of this it is important to include regular cardiac appraisal as part of the routine assessment in seropositive juvenile arthritis.

Rheumatoid aortic valve prolapse requiring emergency aortic valve replacement

Rapid progression of aortic regurgitation was closely observed in a patient with severe seropositive rheumatoid arthritis. Rheumatoid changes within the aortic valve leaflets resulted in severe prolapse necessitating emergency operation. The postoperative course was satisfactory.

Successful valve replacement for aortic incompetence in rheumatoid arthritis with vasculitis

A patient with rheumatoid arthritis (RA), vasculitis, and aortic valve incompetence of the histologically nonspecific type is described. Valve replacement was undertaken, and an excellent haemodynamic result was achieved. Both arthritis and vasculitis subsequently remitted. Valve replacement can be successfully performed in RA despite active vasculitis.

Cardiac involvement in rheumatoid arthritis. Followup study

Initial studies from Bowman Gray School of Medicine showed that 18 of 30 patients with classic rheumatoid arthritis (RA) had cardiac involvement from their disease. These abnormalities were detected by echocardiography and consisted of mitral valve and/or pericardial abnormalities. All patients were followed for 4 years from the initial workup. Mitral valve abnormalities were seen on followup in 63% of the patients who initially showed this abnormality, while pericardial effusion remained in 20%. Pericardial thickening persisted in 6 of 7 patients. None of the patients developed constrictive pericarditis or heart failure. There was no definite correlation between persistence of these abnormalities and other clinical data, but it was noticed that patients who had persistent pericardial effusion and mitral valve abnormalities showed a higher number of involved joints and a higher erythrocyte sedimentation rate. The cardiac abnormalities described in this study have remained clinically insignificant in this population of RA patients.

Aortic valve replacement in rheumatoid aortic incompetence

Rheumatoid aortic valve disease is uncommon. and there are few reports of valve replacement in this condition. Aortic valve replacement and partial pericardiectomy was performed in a patient with acute rheumatoid aortitis and aortic incompetence. Previous reports suggest that any patient with rheumatoid arthritis who develops cardiac symptoms should be carefully assessed for surgically treatable involvement of the pericardium or heart valves.

Cardiac valvular disease in chronic inflammatory disorders of connective tissue. Factors influencing survival after surgery

Three cases of cardiac valvular disease complicating chronic inflammatory disorders of connective tissue are described. Each underwent surgical valve replacement. The outcome in the first case, a patient with aortitis complicating Reiter's syndrome and in good health otherwise, has been excellent. The other two patients, one with rheumatoid arthritis and vasculitis, the other with systemic lupus erythematosus and nephritis, died after operation as the result of their systemic disease. The importance of systemic features in assessing this type of patient is emphasized.