To the Editor:
Heart valve pathology is commonly recognized in systemic lupus erythematosus (SLE)1. Immunoglobulin and complement deposition in the valvular structure consequently leads to valve thickening, Libman-Sacks vegetations, and valve regurgitation1. Involvement of the mitral valve (MV) is most frequently encountered. Valvular stenosis is rarely seen1. This is the first report to describe the value of live real-time 3-dimensional echocardiography (RT3DE) in the diagnosis of SLE-related MV stenosis.
A 68-year-old woman with a history of longstanding SLE and new onset of atrial fibrillation was admitted with dyspnea on exertion over the past year, deteriorating progressively during the last month. A standard transthoracic 2-dimensional (2-D) echocardiogram performed with a Vivid 7 Dimension system (GE Medical Systems, Milwaukee, WI, USA) revealed normal left ventricular size and systolic function, right ventricular dilatation with impaired systolic function, left atrium enlargement, MV leaflet thickening, and mild MV stenosis (MV area = 1.6 cm2, Figure 1A) with trivial regurgitation. Moderate tricuspid regurgitation was detected with estimated right ventricular systolic pressure of approximately 60 mm Hg. After the 2-D examination, complementary MV assessment by RT3DE was carried out, using the same ultrasound system and a 3V full-matrix array transducer capable of online, real-time non-gated 3-D imaging and rendering as well as full-volume 3-D imaging with gated acquisition. The resultant 3-D data were processed using dedicated software (EchoPAC; GE Medical Systems). RT3DE confirmed the 2-D echocardiographic findings with respect to MV morphology and severity of stenosis (Figure 1B, 1C, 1D).
Comparing with 2-D echocardiography, RT3DE allows a more “realistic” visualization of the heart2. Implementation of the RT3DE with the new generation of full-matrix array transducers, capable of online 3-D rendering, offers advantages over 2-D echocardiography for assessment of the morphology, function, and pathology of the MV apparatus. Due to the variable geometry of the stenotic MV orifice, correct plane orientation frequently becomes difficult. Navigation and cropping tools incorporated into the commercial software packages for 3-D data analysis allow optimization of the cut planes that would provide unique en face views of the stenotic MV from which accurate measurements of the MV area can be made (Figure 1D). Available evidence suggests that RT3DE provides improved accuracy and reproducibility over 2-D methods for the calculation of MV area in patients with rheumatic and calcific MV stenosis2,3, yet its use in SLE-related valvulopathy has not been clinically implemented. In patients with SLE and suspected cardioembolism, acute or subacute Libman-Sacks endocarditis with moderate or worse valve dysfunction, transesophageal 2-D echocardiography appears superior to transthoracic 2-D echocardiography4. The diagnostic accuracy of transesophageal 2-D echocardiography in comparison with that of transthoracic RT3DE, in this group of patients, remains to be examined.
Acknowledgments
We thank Prof. Haralampos Moutsopoulos for his continuous inspiration, guidance, and support.
Footnotes
REFERENCES
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