Libman-Sacks endocarditis: Difference between revisions

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==Differential Diagnosis==
==Differential Diagnosis==
Myocardial Abscess should be differentiated from other diseases presenting with [[fever]], [[chest pain]] and [[anorxia]]. The differentials include the following:<ref name="pmid24550636">{{cite journal |vauthors=Brenes-Salazar JA |title=Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era |journal=J Emerg Trauma Shock |volume=7 |issue=1 |pages=57–8 |year=2014 |pmid=24550636 |pmc=3912657 |doi=10.4103/0974-2700.125645 |url=}}</ref><ref name="urlCT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics">{{cite web |url=http://pubs.rsna.org/doi/full/10.1148/rg.245045008 |title=CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis &#124; RadioGraphics |format= |work= |accessdate=}}</ref><ref name="pmid23940438">{{cite journal |vauthors=Bĕlohlávek J, Dytrych V, Linhart A |title=Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism |journal=Exp Clin Cardiol |volume=18 |issue=2 |pages=129–38 |year=2013 |pmid=23940438 |pmc=3718593 |doi= |url=}}</ref><ref name="urlPulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022657/ |title=Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health |format= |work= |accessdate=}}</ref><ref name="pmid20118395">{{cite journal |vauthors=Ramani GV, Uber PA, Mehra MR |title=Chronic heart failure: contemporary diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=2 |pages=180–95 |year=2010 |pmid=20118395 |pmc=2813829 |doi=10.4065/mcp.2009.0494 |url=}}</ref><ref name="pmid18215495">{{cite journal |vauthors=Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL |title=Symptom distress and quality of life in patients with advanced congestive heart failure |journal=J Pain Symptom Manage |volume=35 |issue=6 |pages=594–603 |year=2008 |pmid=18215495 |pmc=2662445 |doi=10.1016/j.jpainsymman.2007.06.007 |url=}}</ref><ref name="pmid19168510">{{cite journal |vauthors=Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ |title=Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology |journal=Eur. J. Heart Fail. |volume=11 |issue=2 |pages=130–9 |year=2009 |pmid=19168510 |pmc=2639415 |doi=10.1093/eurjhf/hfn013 |url=}}</ref><ref name="pmid9465867">{{cite journal |vauthors=Takasugi JE, Godwin JD |title=Radiology of chronic obstructive pulmonary disease |journal=Radiol. Clin. North Am. |volume=36 |issue=1 |pages=29–55 |year=1998 |pmid=9465867 |doi= |url=}}</ref><ref name="pmid14651761">{{cite journal |vauthors=Wedzicha JA, Donaldson GC |title=Exacerbations of chronic obstructive pulmonary disease |journal=Respir Care |volume=48 |issue=12 |pages=1204–13; discussion 1213–5 |year=2003 |pmid=14651761 |doi= |url=}}</ref><ref name="pmid23833163">{{cite journal |vauthors=Nakawah MO, Hawkins C, Barbandi F |title=Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome |journal=J Am Board Fam Med |volume=26 |issue=4 |pages=470–7 |year=2013 |pmid=23833163 |doi=10.3122/jabfm.2013.04.120256 |url=}}</ref><ref name="pmid20511488">{{cite journal |vauthors=Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK |title=Pericardial disease: diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=6 |pages=572–93 |year=2010 |pmid=20511488 |pmc=2878263 |doi=10.4065/mcp.2010.0046 |url=}}</ref><ref name="pmid23610095">{{cite journal |vauthors=Bogaert J, Francone M |title=Pericardial disease: value of CT and MR imaging |journal=Radiology |volume=267 |issue=2 |pages=340–56 |year=2013 |pmid=23610095 |doi=10.1148/radiol.13121059 |url=}}</ref><ref name="pmid11680112">{{cite journal |vauthors=Gharib AM, Stern EJ |title=Radiology of pneumonia |journal=Med. Clin. North Am. |volume=85 |issue=6 |pages=1461–91, x |year=2001 |pmid=11680112 |doi= |url=}}</ref><ref name="pmid23507061">{{cite journal |vauthors=Schmidt WA |title=Imaging in vasculitis |journal=Best Pract Res Clin Rheumatol |volume=27 |issue=1 |pages=107–18 |year=2013 |pmid=23507061 |doi=10.1016/j.berh.2013.01.001 |url=}}</ref><ref name="pmid16891436">{{cite journal |vauthors=Suresh E |title=Diagnostic approach to patients with suspected vasculitis |journal=Postgrad Med J |volume=82 |issue=970 |pages=483–8 |year=2006 |pmid=16891436 |pmc=2585712 |doi=10.1136/pgmj.2005.042648 |url=}}</ref><ref name="pmid123074">{{cite journal |vauthors=Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW |title=The electrocardiogram in acute pulmonary embolism |journal=Prog Cardiovasc Dis |volume=17 |issue=4 |pages=247–57 |year=1975 |pmid=123074 |doi= |url=}}</ref><ref name="pmid23413894">{{cite journal |vauthors=Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML |title=Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease |journal=COPD |volume=10 |issue=1 |pages=62–71 |year=2013 |pmid=23413894 |doi=10.3109/15412555.2012.727918 |url=}}</ref><ref name="pmid23000104">{{cite journal |vauthors=Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H |title=Electrocardiogram in pneumonia |journal=Am. J. Cardiol. |volume=110 |issue=12 |pages=1836–40 |year=2012 |pmid=23000104 |doi=10.1016/j.amjcard.2012.08.019 |url=}}</ref><ref name="pmid26209947">{{cite journal |vauthors=Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S |title=Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis |journal=Int. J. Cardiol. |volume=199 |issue= |pages=170–9 |year=2015 |pmid=26209947 |doi=10.1016/j.ijcard.2015.06.087 |url=}}</ref><ref name="pmid20112390">{{cite journal |vauthors=Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S |title=Cardiac involvement in Churg-Strauss syndrome |journal=Arthritis Rheum. |volume=62 |issue=2 |pages=627–34 |year=2010 |pmid=20112390 |doi=10.1002/art.27263 |url=}}</ref>
:*Thrombotic nonbacterial endocarditis/Marantic endocarditis
:*Thrombotic nonbacterial endocarditis/Marantic endocarditis
:*Vasculitis
:*Vasculitis
Line 124: Line 127:
:*Intra-abdominal infections
:*Intra-abdominal infections
:*Septic pulmonary infarction
:*Septic pulmonary infarction
Myocardial Abscess should be differentiated from other diseases presenting with [[fever]], [[chest pain]] and [[anorxia]]. The differentials include the following:<ref name="pmid24550636">{{cite journal |vauthors=Brenes-Salazar JA |title=Westermark's and Palla's signs in acute and chronic pulmonary embolism: Still valid in the current computed tomography era |journal=J Emerg Trauma Shock |volume=7 |issue=1 |pages=57–8 |year=2014 |pmid=24550636 |pmc=3912657 |doi=10.4103/0974-2700.125645 |url=}}</ref><ref name="urlCT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis | RadioGraphics">{{cite web |url=http://pubs.rsna.org/doi/full/10.1148/rg.245045008 |title=CT Angiography of Pulmonary Embolism: Diagnostic Criteria and Causes of Misdiagnosis &#124; RadioGraphics |format= |work= |accessdate=}}</ref><ref name="pmid23940438">{{cite journal |vauthors=Bĕlohlávek J, Dytrych V, Linhart A |title=Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism |journal=Exp Clin Cardiol |volume=18 |issue=2 |pages=129–38 |year=2013 |pmid=23940438 |pmc=3718593 |doi= |url=}}</ref><ref name="urlPulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health">{{cite web |url=https://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0022657/ |title=Pulmonary Embolism: Symptoms - National Library of Medicine - PubMed Health |format= |work= |accessdate=}}</ref><ref name="pmid20118395">{{cite journal |vauthors=Ramani GV, Uber PA, Mehra MR |title=Chronic heart failure: contemporary diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=2 |pages=180–95 |year=2010 |pmid=20118395 |pmc=2813829 |doi=10.4065/mcp.2009.0494 |url=}}</ref><ref name="pmid18215495">{{cite journal |vauthors=Blinderman CD, Homel P, Billings JA, Portenoy RK, Tennstedt SL |title=Symptom distress and quality of life in patients with advanced congestive heart failure |journal=J Pain Symptom Manage |volume=35 |issue=6 |pages=594–603 |year=2008 |pmid=18215495 |pmc=2662445 |doi=10.1016/j.jpainsymman.2007.06.007 |url=}}</ref><ref name="pmid19168510">{{cite journal |vauthors=Hawkins NM, Petrie MC, Jhund PS, Chalmers GW, Dunn FG, McMurray JJ |title=Heart failure and chronic obstructive pulmonary disease: diagnostic pitfalls and epidemiology |journal=Eur. J. Heart Fail. |volume=11 |issue=2 |pages=130–9 |year=2009 |pmid=19168510 |pmc=2639415 |doi=10.1093/eurjhf/hfn013 |url=}}</ref><ref name="pmid9465867">{{cite journal |vauthors=Takasugi JE, Godwin JD |title=Radiology of chronic obstructive pulmonary disease |journal=Radiol. Clin. North Am. |volume=36 |issue=1 |pages=29–55 |year=1998 |pmid=9465867 |doi= |url=}}</ref><ref name="pmid14651761">{{cite journal |vauthors=Wedzicha JA, Donaldson GC |title=Exacerbations of chronic obstructive pulmonary disease |journal=Respir Care |volume=48 |issue=12 |pages=1204–13; discussion 1213–5 |year=2003 |pmid=14651761 |doi= |url=}}</ref><ref name="pmid23833163">{{cite journal |vauthors=Nakawah MO, Hawkins C, Barbandi F |title=Asthma, chronic obstructive pulmonary disease (COPD), and the overlap syndrome |journal=J Am Board Fam Med |volume=26 |issue=4 |pages=470–7 |year=2013 |pmid=23833163 |doi=10.3122/jabfm.2013.04.120256 |url=}}</ref><ref name="pmid20511488">{{cite journal |vauthors=Khandaker MH, Espinosa RE, Nishimura RA, Sinak LJ, Hayes SN, Melduni RM, Oh JK |title=Pericardial disease: diagnosis and management |journal=Mayo Clin. Proc. |volume=85 |issue=6 |pages=572–93 |year=2010 |pmid=20511488 |pmc=2878263 |doi=10.4065/mcp.2010.0046 |url=}}</ref><ref name="pmid23610095">{{cite journal |vauthors=Bogaert J, Francone M |title=Pericardial disease: value of CT and MR imaging |journal=Radiology |volume=267 |issue=2 |pages=340–56 |year=2013 |pmid=23610095 |doi=10.1148/radiol.13121059 |url=}}</ref><ref name="pmid11680112">{{cite journal |vauthors=Gharib AM, Stern EJ |title=Radiology of pneumonia |journal=Med. Clin. North Am. |volume=85 |issue=6 |pages=1461–91, x |year=2001 |pmid=11680112 |doi= |url=}}</ref><ref name="pmid23507061">{{cite journal |vauthors=Schmidt WA |title=Imaging in vasculitis |journal=Best Pract Res Clin Rheumatol |volume=27 |issue=1 |pages=107–18 |year=2013 |pmid=23507061 |doi=10.1016/j.berh.2013.01.001 |url=}}</ref><ref name="pmid16891436">{{cite journal |vauthors=Suresh E |title=Diagnostic approach to patients with suspected vasculitis |journal=Postgrad Med J |volume=82 |issue=970 |pages=483–8 |year=2006 |pmid=16891436 |pmc=2585712 |doi=10.1136/pgmj.2005.042648 |url=}}</ref><ref name="pmid123074">{{cite journal |vauthors=Stein PD, Dalen JE, McIntyre KM, Sasahara AA, Wenger NK, Willis PW |title=The electrocardiogram in acute pulmonary embolism |journal=Prog Cardiovasc Dis |volume=17 |issue=4 |pages=247–57 |year=1975 |pmid=123074 |doi= |url=}}</ref><ref name="pmid23413894">{{cite journal |vauthors=Warnier MJ, Rutten FH, Numans ME, Kors JA, Tan HL, de Boer A, Hoes AW, De Bruin ML |title=Electrocardiographic characteristics of patients with chronic obstructive pulmonary disease |journal=COPD |volume=10 |issue=1 |pages=62–71 |year=2013 |pmid=23413894 |doi=10.3109/15412555.2012.727918 |url=}}</ref><ref name="pmid23000104">{{cite journal |vauthors=Stein PD, Matta F, Ekkah M, Saleh T, Janjua M, Patel YR, Khadra H |title=Electrocardiogram in pneumonia |journal=Am. J. Cardiol. |volume=110 |issue=12 |pages=1836–40 |year=2012 |pmid=23000104 |doi=10.1016/j.amjcard.2012.08.019 |url=}}</ref><ref name="pmid26209947">{{cite journal |vauthors=Hazebroek MR, Kemna MJ, Schalla S, Sanders-van Wijk S, Gerretsen SC, Dennert R, Merken J, Kuznetsova T, Staessen JA, Brunner-La Rocca HP, van Paassen P, Cohen Tervaert JW, Heymans S |title=Prevalence and prognostic relevance of cardiac involvement in ANCA-associated vasculitis: eosinophilic granulomatosis with polyangiitis and granulomatosis with polyangiitis |journal=Int. J. Cardiol. |volume=199 |issue= |pages=170–9 |year=2015 |pmid=26209947 |doi=10.1016/j.ijcard.2015.06.087 |url=}}</ref><ref name="pmid20112390">{{cite journal |vauthors=Dennert RM, van Paassen P, Schalla S, Kuznetsova T, Alzand BS, Staessen JA, Velthuis S, Crijns HJ, Tervaert JW, Heymans S |title=Cardiac involvement in Churg-Strauss syndrome |journal=Arthritis Rheum. |volume=62 |issue=2 |pages=627–34 |year=2010 |pmid=20112390 |doi=10.1002/art.27263 |url=}}</ref>


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Revision as of 03:14, 6 February 2020

Libman-Sacks endocarditis
ICD-10 I39, M32.1
ICD-9 710.0
DiseasesDB 29254
eMedicine med/1295 
MeSH D008180

Template:Search infobox Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Mohsin, M.D.[2]

Synonyms and keywords: Nonbacterial thrombotic endocarditis (NBTE), Marantic endocarditis, Verrucous endocarditis

Overview

Libman-Sacks endocarditis is a form of nonbacterial endocarditis that is seen in systemic lupus erythematosus. It is the most common cardiac manifestation of lupus. It can be associated with the development of aortic insufficiency. LSE is a sterile and verrucous vegetation around the heart valves. LSE is usually associated with autoimmune diseases especially SLE and APS. LSE mostly affects mitral and aortic heart valves, which may cause thromboembolic cerebrovascular events, valvular regurgitation, and increased risk of infective endocarditis. Although APS and valvular involvements are not rare, and have mostly low clinical significance, they could cause severe complications. Secondary APS compared to primary APS also have higher rate of cardiac involvement, mostly due to the autoimmune causes related to the SLE. Here, we report three cases of LSE in patients with SLE and secondary APS diagnosed after presenting with neurological manifestations.

Historical Perspective

Pathophysiology

Pathology

  • The pathology is the same as nonbacterial thrombotic endocarditis except focal necrosis (hematoxylin bodies) can be found only in Libman-Sacks endocarditis.

Epidemiology and Demographics

Natural History, Complications and Prognosis

Complications

  • Systemic emboli may occur but they are probably not very common.
  • The risk is much higher with mitral stenosis and subsequent atrial fibrillation.
  • When strokes occur it is difficult to know if they were due to systemic emboli or the underlying pathology of SLE or APS.
  • Valvular disease can lead to heart failure.
  • Maternal SLE with anti-Ro/SS-A (Sjögren's syndrome antigen A) autoantibodies is associated with congenital heart block in the baby in about 1 or 2%. It is usually complete but can be 1st or 2nd degree.
  • The rate of recurrence is around 16%.
  • Fluorinated steroids that do not cross the placenta may be beneficial.

Prognosis

  • All the SLE patients have a shorter life span.
  • The major cause of mortality in SLE patients is occurrence of cardiovascular events as SLE is a risk factor for premature & accelerated coronary atherosclerosis and CAD (coronary artery disease) due to the following associated factors:
    • Hypertension
    • Hyperlipidemia
    • Chronic inflammation
    • Chronic glucocorticoids use

History and symptoms

  • Most patients with Libman-Sacks endocarditis are asymptomatic.
  • If valves are severely affected there may be features of the valve disease.
  • Mitral valve disease is more common than aortic valve disease.
  • Regurgitation is more frequent than stenosis and involvement of the tricuspid or pulmonary valves is unusual.
  • Systemic embolism may occur with effects depending upon the destination of the emboli but brain and kidney are likely victims.
  • Emboli can cause blockage of the peripheral circulation.
  • The vegetations of Libman-Sacks endocarditis are sterile but secondary infective endocarditis can occur.
  • There may or may not be typical features of SLE with the characteristic butterfly rash, fever and arthritis or features of APS, including recurrent miscarriage.

Physical Examination

  • left ventricular hypertrophy, causing displacement of the apex beat.
  • congestive heart failure physical exam findings.
  • IE findings
  • Mitral valve disease findings
  • Aortic valve disease findings

Laboratory findings

  • Blood culture is important to exclude infective endocarditis (IE), which may coexist.
  • Investigations for SLE, including antiphospholipid antibodies and other autoantibodies. False-positive serology in the form of VDRL is common in SLE and anticardiolipin antibodies increase the risk of cardiac abnormalities.
  • FBC may show raised neutrophils and some anaemia.

Imaging findings

Echocardiography

  • Echocardiography should be employed, although not all lesions will be detected.
  • Results with transoesophageal echo are superior but it is an invasive procedure.

Chest X-Ray

  • CXR may show cardiomegaly and pulmonary congestion if the disease is severe.
  • Calcification of lesions is uncommon.

Other Diagnostic studies

Cardiac Catheterization

  • If valvular disease seems severe then cardiac catheterization may be required with a view to valve replacement.

Treatment

  • There is no specific treatment for Libman-Sacks endocarditis.
  • Steroids and immunosuppressive agents are useful in the treatment of the underlying disease but there is some controversy about their role in the pathogenesis of vegetations:
    • Compared with reports of postmortems on patients before the advent of steroids, those that have been treated have smaller and fewer lesions, mostly on one valve and usually confined to the left side.
    • Hypertension was 5 times as common and congestive heart failure was 8 times as common as in the days before corticosteroids. The steroids may be directly responsible for hypertension and heart failure. This paper was from 1975 and it is possible that better control of hypertension and heart failure may offset these problems today.
    • Expert opinion seems to conclude that steroids are detrimental to Libman-Sacks endocarditis although some praise them. The situation is far from certain.
  • Advice for procedures creating a risk of infective endocarditis can be found in the separate record Prevention of Endocarditis.
  • If there are systemic emboli then anticoagulation with warfarin is beneficial but the possible role of aspirin has not been adequately investigated. If there is evidence of 1 cerebrovascular event, anticoagulation is advised.
  • In serious valve disease it may be necessary to replace valves. Mechanical valves may be more susceptible to thromboemboli but it is uncertain if bioprosthetic valves are at risk of the disease. The operative mortality of mitral valve replacement in this condition may be as high as 25%.

Differential Diagnosis

Myocardial Abscess should be differentiated from other diseases presenting with fever, chest pain and anorxia. The differentials include the following:[24][25][26][27][28][29][30][31][32][33][34][35][36][37][38][39][40][41][42][43]

  • Thrombotic nonbacterial endocarditis/Marantic endocarditis
  • Vasculitis
  • Temporal arteritis
  • SLE/Libman-Sacks endocarditis
  • Connective tissue disease
  • Fever of unknown origin (FUO)
  • Intra-abdominal infections
  • Septic pulmonary infarction

Diseases Diagnostic tests Physical Examination Symptoms Past medical history Other Findings
CT scan and MRI EKG Chest X-ray Tachypnea Tachycardia Fever Chest Pain Hemoptysis Dyspnea on Exertion Wheezing Chest Tenderness Nasalopharyngeal Ulceration Carotid Bruit
Pulmonary embolism
  • On CT angiography:
    • Intra-luminal filling defect
  • On MRI:
    • Narrowing of involved vessel
    • No contrast seen distal to obstruction
    • Polo-mint sign (partial filling defect surrounded by contrast)
✔ (Low grade) ✔ (In case of massive PE) - - - -
Infective Endocarditis
  • Goldberg's criteria may aid in diagnosis of left ventricular dysfunction: (High specificity)
    • SV1 or SV2 + RV5 or RV6 ≥3.5 mV
    • Total QRS amplitude in each of the limb leads ≤0.8 mV
    • R/S ratio <1 in lead V4
- - - - - -
Non-Bacterial Thrombotic Endocarditis
  • ST elevation
  • PR depression
✔ (Low grade) ✔ (Relieved by sitting up and leaning forward) - - - - -
  • May be clinically classified into:
    • Acute (< 6 weeks)
    • Sub-acute (6 weeks - 6 months)
    • Chronic (> 6 months)
Libman Sack Endocarditis - - - -
Vasculitis

Homogeneous, circumferential vessel wall swelling

-
Fever of unknown origin (FUO) - - - - - -

References

  1. Libman E, Sacks B: A hitherto undescribed form of valvular and mural endocarditis. Arch Intern Med 1924; 33: 701-37.
  2. Libman, Emanuel (1924). "A HITHERTO UNDESCRIBED FORM OF VALVULAR AND MURAL ENDOCARDITIS". Archives of Internal Medicine. 33 (6): 701. doi:10.1001/archinte.1924.00110300044002. ISSN 0003-9926.
  3. https://patient.info/doctor/libman-sacks-endocarditis#ref-14
  4. Mohammadi Kebar Y, Avesta L, Habibzadeh A, Hemmati M (2019). "Libman-Sacks endocarditis in patients with systemic lupus erythematosus with secondary antiphospholipid syndrome". Caspian J Intern Med. 10 (3): 339–342. doi:10.22088/cjim.10.3.339. PMC 6729157 Check |pmc= value (help). PMID 31558998.
  5. Murtaza G, Iskandar J, Humphrey T, Adhikari S, Kuruvilla A (2017). "Lupus-Negative Libman-Sacks Endocarditis Complicated by Catastrophic Antiphospholipid Syndrome". Cardiol Res. 8 (2): 57–62. doi:10.14740/cr534e. PMC 5421487. PMID 28515823.
  6. Bouma W, Klinkenberg TJ, van der Horst IC, Wijdh-den Hamer IJ, Erasmus ME, Bijl M; et al. (2010). "Mitral valve surgery for mitral regurgitation caused by Libman-Sacks endocarditis: a report of four cases and a systematic review of the literature". J Cardiothorac Surg. 5: 13. doi:10.1186/1749-8090-5-13. PMC 2859362. PMID 20331896.
  7. Bai Z, Hou J, Ren W, Guo Y (2015). "Diagnosis and surgical treatment for isolated tricuspid Libman-Sacks endocarditis: a rare case report and literatures review". J Cardiothorac Surg. 10: 93. doi:10.1186/s13019-015-0302-1. PMC 4494164. PMID 26152222.
  8. "StatPearls". 2019. PMID 30422459.
  9. Wang Y, Ma C, Yang J, Liu S, Zhang Y, Zhao L; et al. (2015). "Libman-sacks endocarditis exclusively involving the tricuspid valve in a patient with systemic lupus erythematosus". J Clin Ultrasound. 43 (4): 265–267. doi:10.1002/jcu.22180. PMID 24925796.
  10. Perier P, Jeserich M, Vieth M, Pohle K, Hohenberger W, Diegeler A (2011). "Mitral valve reconstruction in a patient with Libman-Sacks endocarditis: a case report". J Heart Valve Dis. 20 (1): 103–6. PMID 21404907.
  11. Bani Hani A, Abu-Abeeleh M, Al Kharabsheh MM, Qabba'ah L (2016). "Libman-Sacks Endocarditis with Unusual Large Size Vegetation Involving the Mitral Valve". Heart Surg Forum. 19 (6): E294–E296. doi:10.1532/hsf.1612. PMID 28054901.
  12. https://patient.info/doctor/libman-sacks-endocarditis#ref-14
  13. Deppisch LM, Fayemi AO (1976). "Non-bacterial thrombotic endocarditis: clinicopathologic correlations". Am Heart J. 92 (6): 723–9. doi:10.1016/s0002-8703(76)80008-7. PMID 998478.
  14. Rosen P, Armstrong D (1973). "Nonbacterial thrombotic endocarditis in patients with malignant neoplastic diseases". Am J Med. 54 (1): 23–9. doi:10.1016/0002-9343(73)90079-x. PMID 4682494.
  15. Llenas-García J, Guerra-Vales JM, Montes-Moreno S, López-Ríos F, Castelbón-Fernández FJ, Chimeno-García J (2007). "[Nonbacterial thrombotic endocarditis: clinicopathologic study of a necropsy series]". Rev Esp Cardiol. 60 (5): 493–500. PMID 17535760.
  16. Eiken PW, Edwards WD, Tazelaar HD, McBane RD, Zehr KJ (2001). "Surgical pathology of nonbacterial thrombotic endocarditis in 30 patients, 1985-2000". Mayo Clin Proc. 76 (12): 1204–12. doi:10.4065/76.12.1204. PMID 11761501.
  17. Mazokopakis EE, Syros PK, Starakis IK (2010). "Nonbacterial thrombotic endocarditis (marantic endocarditis) in cancer patients". Cardiovasc Hematol Disord Drug Targets. 10 (2): 84–6. doi:10.2174/187152910791292484. PMID 20397972.
  18. Lopez JA, Ross RS, Fishbein MC, Siegel RJ (1987). "Nonbacterial thrombotic endocarditis: a review". Am Heart J. 113 (3): 773–84. doi:10.1016/0002-8703(87)90719-8. PMID 3548296.
  19. el-Shami K, Griffiths E, Streiff M (2007). "Nonbacterial thrombotic endocarditis in cancer patients: pathogenesis, diagnosis, and treatment". Oncologist. 12 (5): 518–23. doi:10.1634/theoncologist.12-5-518. PMID 17522239.
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