IMAGE SECTION Section Editor: Brian D. Hoit, M.D.

A Vanishing Left Ventricular Outflow Tract Mass: AnUncommon Manifestation of Systemic LupusErythematosus

Rajiv Ananthakrishna, D.M., Nagaraja Moorthy, D.M., Prabhavathi Bhat, D.M., andManjunath C Nanjappa, D.M.

Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences & Research, Bangalore, India

(Echocardiography 2014;31:E222–E223)

Key words: echocardiography, mass, thrombus

A 27-year-old female, with a history of sec-ond trimester abortion was referred for evalua-tion of transient ischemic attack. Cardiovascularexamination revealed an ejection systolic mur-mur in the aortic area. Echocardiographyrevealed a large, irregular, mobile mass attachedto the right coronary cusp of aortic valve(Fig. 1A and 1B; movie clips S1 and S2). The gra-dient across the aortic valve was 54/35 mmHg.Differential diagnosis considered includes throm-bus, vegetation, and papillary fibroelastoma.Rarely, accessory mitral valve tissue and myxomacause left ventricular outflow tract obstruc-tion.1,2 Complete hemogram was within normal

limits. Coagulation profile revealed diagnostictiters of anticardiolipin antibody and lupus anti-coagulant, consistent with antiphospholipidantibody syndrome. In addition, patient had evi-dence suggestive of systemic lupus erythemato-sus (SLE) (photosensitivity, nonerosive arthritis,positive ANA and anti-ds DNA). There were norenal and neurological manifestations of SLE.She was started on oral anticoagulation to main-tain therapeutic international normalized ratio.Serial echocardiography showed regression ofthe mass. At 2 months, patient was asymptom-atic with an international normalized ratio of3.2. Repeat echocardiography showed complete

Figure 1. A. Two-dimensional transesophageal echocardiography depicting a large, irregular, mobile mass attached to the rightcoronary cusp of the aortic valve. B. Three-dimensional transesophageal echocardiography illustrating the mass in relation toaortic valve.

Address for correspondence and reprint requests: Rajiv Ana-nthakrishna, D.M., Sri Jayadeva Institute of Cardiovascular Sci-ences & Research, Jaya Nagar 9th Block, BG Road, Bangalore560069, India. Fax: +918026534477;E-mail: rajiva.ms@gmail.com

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© 2014, Wiley Periodicals, Inc.DOI: 10.1111/echo.12598 Echocardiography

resolution of the mass, with laminar flow acrossthe aortic valve (Fig. 2A and 2B; movie clips S3and S4). The aortic valve was structurallynormal. There was no evidence of systemicembolization.

Thrombosis is seen in one-third of individualswith SLE.3 It is significant, as thrombotic diseaseis one of the common causes of cardiovascularmortality in SLE.4 Our patient presented with athrombotic mass on the aortic valve, causingobstruction and embolism. Libman-Sacks endo-carditis is an important differential diagnosis inSLE. These lesions are sterile, fibrinous vegeta-tions with a propensity for the left-sided valves,particularly the ventricular surface of the mitralvalve. On echocardiography, these vegetationsappear as small masses with irregular bordersand echo density, with firm attachment to thevalve surface and exhibiting no independentmobility. There will be formation of fibrin-plateletthrombi on the altered valve, the organization ofwhich leads to fibrosis and subsequent valve dys-function. In this report, there was a large throm-bus attached to the aortic valve, withindependent mobility. In addition, the underly-ing aortic valve was structurally normal. Therewas prompt response to anticoagulation, withcomplete resolution of the thrombus. Thesefactors differentiated thrombus from Libman-Sacks endocarditis.

To conclude, in the presence of a hypercoa-guable state, cardiac mass is usually secondary toa thrombus. We highlight an uncommon mani-festation of SLE, in the setting of a prothromboticmilieu. Prompt recognition is essential for appro-priate therapy and averts the need for surgery.

References1. Gurzun MM, Husain F, Zaidi A, et al: Accessory mitral

valve-an unexpected intra-operative TEE finding causingleft ventricular outflow tract obstruction in an adult. Echo-cardiography 2014;31:E55–E57.

2. Rao RV, Walsh S, Chan V, et al: Unusual cause of an ejec-tion murmur: Myxoma in the left ventricular outflow tract.Can J Cardiol 2013;29:1742.e13–1742.e15.

3. Panchal L, Divate S, Vaideeswar P, et al: Cardiovascularinvolvement in systemic lupus erythematosus: An autopsystudy of 27 patients in India. J Postgrad Med 2006;52:5–10.

4. Trager J, Ward MM: Mortality and causes of death in sys-temic lupus erythematosus. Curr Opin Rheumatol2001;13:345–351.

Supporting InformationAdditional Supporting Information may be foundin the online version of this article:

Movie clip S1 for Figure 1A.Movie clip S2 for Figure 1B.Movie clip S3 for Figure 2A.Movie clip S4 for Figure 2B.

Figure 2. A. Two-dimensional transesophageal echocardiography, 2 months after therapeutic anticoagulation showing resolu-tion of thrombus, with laminar flow across the aortic valve. B. Three-dimensional transesophageal echocardiography confirmingthe resolution of thrombus following anticoagulation. (AO = aorta; LA = left atrium; LVOT = left ventricular outflow tract;RV = right ventricle).

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Aortic Valve Thrombosis Secondary to SLE