There was minimal pericardial effusion seen but no intracardiac thrombus
There was minimal pericardial effusion seen but no intracardiac thrombus. the patient was discharged well. Conclusions Classically Libman-Sacks endocarditis is usually often and more commonly associated with autoimmune diseases such as systemic lupus erythematosus, although it can occur in both primary and secondary antiphospholipid syndrome. It is not a common entity, and it is a frequent underestimated disease as most clinicians do not routinely screen for valvular lesion in patients with antiphospholipid syndrome unless they are symptomatic. However, due to its high prevalence of cardiac involvement, clinicians should have a high index of suspicion in the attempt to minimize cardiovascular and haemodynamic complications. Valve surgery in patients with antiphospholipid syndrome carries considerable early and late morbidity and mortality, usually caused by thromboembolic and bleeding events. The perioperative anticoagulation management and haemostatic aspect of antiphospholipid syndrome present an exceptional challenges to clinicians, surgeons, anaesthetists and laboratory personnel. Keywords: Antiphospholipid syndrome, Antiphospholipid antibodies, Libman-sacks endocarditis, Cardiac manifestations, Heart valve disease, Aortic regurgitation, Valve replacement surgery Background Antiphospholipid syndrome (APS) is usually a rare coagulative disorder with antiphospholipid antibody mediated pro-thrombotic state mainly characterised by hypercoagulable complications. Cardiac manifestations of APS include arterial or venous thromboses, valve diseases, coronary artery disease, intracardiac thrombus, pulmonary hypertension and dilated cardiomyopathy, with the functional impairment of heart valves being the most common manifestation, which commonly associated with Libman-Sacks endocarditis. Libman-Sacks endocarditis, also known as non-bacterial thrombotic, verrucous, or marantic endocarditis, originally described in patients with systemic lupus erythematosus, is usually a well-known complication of Capecitabine (Xeloda) APS. We present a successful aortic valve replacement in a 48?years old lady with aortic valve Libman-sacks endocarditis Capecitabine (Xeloda) and APS who presented with acute pulmonary oedema. Case presentation A 48?years old lady was admitted to cardiology ward complaining of progressively worsening breathlessness, orthopnoea and chest pain for 1?month. Coexisting medical conditions include chronic CD160 hypertension on treatment, with 2 episodes of spontaneous miscarriages previously and 1 episode of transient ischemic attack 3?years ago. Clinically, she was haemodynamically stable with a wide pulse pressure. Finger clubbing was noted with livedo reticularis rashes over bilateral upper and lower limbs without ulcers or thrombophlebitis. Her peripheral pulses were bounding with water-hammered pulse, and a grade III diastolic murmur was heard during cardiac auscultation. In addition, she has elevated jugular venous pressure, crepitation over both lung bases, and Capecitabine (Xeloda) bilateral pedal oedema. Echocardiography showed dilated left atrium and left ventricles with preserved ejection fraction. Severe aortic regurgitation was found with PHT of 156?ms, mean pressure gradient of 32?mmHg, and end diastolic velocity of 29?cm/s. In addition, a vegetation sized 1.2cm2 was seen on aortic valve (Fig.?1). Mild mitral regurgitation was also noted with thickened anterior leaflet. There was minimal pericardial effusion seen but no intracardiac thrombus. Electrocardiography showed normal sinus rhythm with left ventricular hypertrophy and P-mitrale. Coronary angiography was subsequently done which revealed minor coronary disease. Open in a separate windows Fig. 1 Transthoracic echocardiography shows thickened aortic leaftlets with vegetations attached to aortic cusps (red arrow) Blood investigation revealed bicytopenic picture of anemia and thrombocytopenia, with elevated activated partial thromboplastin time (aPTT) and Erythrocyte sedimentation rate (ESR). Otherwise the reports were not suggestive of occult contamination with normal white cell count, C-reactive protein (CRP), and unfavorable.