Mitral Valve Libman-Sacks Endocarditis Visualized by Real-Time 3D Transesophageal Echocardiography

Libman–Sacks endocarditis (LSE) is a common manifestation of valve disease in antiphospholipid syn-drome. Mitral valve LSE is characterized by verrucous vegetations on the atrial surfaces of valve leaflets.In this report, mitral valve LSE was visualized by real-time 3D transesophageal echocardiography (TEE).3D TEE provides a unique en face view of the mitral valve akin to a surgical or autopsy view that allowsfor an accurate determination of the size, shape, and location of the vegetations. (Echocardiography****;**:E1-E2)Key words: 3D TEE, echocardiography, nonbacterial endocarditis, Libman–SacksCase Report:A 68-year-old woman with presumed transient is-chemic attack was referred for transesophagealechocardiography (TEE) to rule out a cardiacsource of emboli. Her past medical history wasnotable for myelodysplastic syndrome and lupus-anticoagulant-associated antiphospholipid syn-drome (APS).Two-dimensional (2D) TEE revealed verrucousmasses on the atrial surfaces of both mitral valve(MV) leaflet tips. The masses measured approx-imately 5 × 5 mm each. They had a “kissinglesion” appearance upon coaptation of the mi-tral valvular leaflets. There was mild to moder-ate mitral regurgitation as well (Fig. 1 and movieclip S1).A real-time, three-dimensional TEE (RT-3DTEE) was performed for further evaluation, anda short-axis, en face view of the MV from the leftatrial perspective was obtained. The 3D TEE re-vealed mound-like protuberances in the regionof A2 and P2 MV scallops along their coaptationsurfaces (Fig. 2; movie clips S2 and S3).Repeated blood cultures were negative. Fur-thermore, there were no clinical or labora-tory findings suggestive of an infective pro-cess, a rheumatologic disorder or malignancy.Giventheclinicalscenario,theechocardiographicfindings were consistent with the diagnosis ofLibman–Sacks nonbacterial thrombotic endo-carditis in the setting of primary (idiopathic)APS.