Left Ventricular Thrombus and Heart Failure With Preserved Ejection Fraction in a Patient With Rheumatoid Arthritis

HomeCirculation: Cardiovascular ImagingVol. 13, No. 6Left Ventricular Thrombus and Heart Failure With Preserved Ejection Fraction in a Patient With Rheumatoid Arthritis Free AccessCase ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessCase ReportPDF/EPUBLeft Ventricular Thrombus and Heart Failure With Preserved Ejection Fraction in a Patient With Rheumatoid ArthritisA Comprehensive Assessment Using Serial Echocardiography Shuang Liu, MD, Jinglun Sun, MD, Liying Xing, MD, Yanmin Pang, MD, Jun Yang, MD, Chunyan Ma, , MD and Limin Zhang, MD Shuang LiuShuang Liu Department of Cardiovascular Ultrasound, First Hospital of China Medical University, Shenyang, Liaoning (S.L., J.S., Y.P., J.Y., C.M., L.Z.). , Jinglun SunJinglun Sun Department of Cardiovascular Ultrasound, First Hospital of China Medical University, Shenyang, Liaoning (S.L., J.S., Y.P., J.Y., C.M., L.Z.). , Liying XingLiying Xing Department of Chronic Disease, Disease Control and Prevention of Liaoning Province, Shenyang, Liaoning, China (L.X.). , Yanmin PangYanmin Pang Department of Cardiovascular Ultrasound, First Hospital of China Medical University, Shenyang, Liaoning (S.L., J.S., Y.P., J.Y., C.M., L.Z.). , Jun YangJun Yang Department of Cardiovascular Ultrasound, First Hospital of China Medical University, Shenyang, Liaoning (S.L., J.S., Y.P., J.Y., C.M., L.Z.). , Chunyan MaChunyan Ma Department of Cardiovascular Ultrasound, First Hospital of China Medical University, Shenyang, Liaoning (S.L., J.S., Y.P., J.Y., C.M., L.Z.). and Limin ZhangLimin Zhang Limin Zhang, MD, Department of Cardiovascular Ultrasound, First Hospital of China Medical University, 155 Nanjing Bei St, Shenyang, Liaoning 110001, China. Email E-mail Address: [email protected] Department of Cardiovascular Ultrasound, First Hospital of China Medical University, Shenyang, Liaoning (S.L., J.S., Y.P., J.Y., C.M., L.Z.). Originally published28 May 2020https://doi.org/10.1161/CIRCIMAGING.119.010222Circulation: Cardiovascular Imaging. 2020;13:e010222A 58-year-old woman was admitted to our hospital for progressive worsening of fatigue and dyspnea over 2 months. The patient had an ≈30-year history of rheumatoid arthritis (RA) and complained of arthralgia for 1 year. Her 28-joint disease activity score was 6.8. Furthermore, she complained of edema for 2 weeks. On admission, she was classified under functional class IV according to the New York Heart Association classification. Physical examination revealed normal blood pressure (131/82 mm Hg), tachypnea, and multiple joint dysfunction; cardiopulmonary auscultations were not prominent. ECG revealed sinus tachycardia. Laboratory tests revealed the following: homocysteine level, 28.69 μmol/L; CRP (C-reactive protein) concentration, 80.71 mg/L; erythrocyte sedimentation rate, 82 mm/h; rheumatoid factor level, 171.9I U/L; anti–cyclic citrullinated peptide antibody level, 793I U/mL; NT-proBNP (N-terminal pro-B-type natriuretic peptide) level, 11881 pg/mL; prothrombin time,16 s; activated partial thromboplastin time, 22.4 s; international normalized ration, 1.23; and D-dimer level, 4.71 μg/mL. Blood count (white blood cells, 9.1×103/μL; granulocytes, 60%; and lymphocytes, 38%) and other laboratory tests for transaminase level, creatinine level, eosinophil count, and serum lipid concentration were normal. Radiographic examination revealed erosions of the hand and wrist joints. High-resolution computed tomography showed bilateral interstitial fibrosis with ground-glass pattern and moderate pleural effusion. Abdominal ultrasound examination confirmed mild liver and spleen enlargement.Transthoracic echocardiography (TTE) revealed prominent obliteration of left ventricular (LV) apex possibly due to thrombosis formation (4.2×2.6 cm; Figure 1A), significant biatrial enlargement with moderate mitral and tricuspid regurgitation (Movie I in the Data Supplement), restrictive pattern of diastolic dysfunction, and preserved LV ejection fraction (65%; Figure 1B and 1C). The estimated systolic pulmonary artery pressure was 85 mm Hg (Figure 1D), the inferior vena cava was significantly dilated (21 mm), and mild pericardial effusion was detected by TTE. Two-dimensional speckle-tracking echocardiography revealed subclinical myocardial dysfunction with a global longitudinal strain of −7.5% (Figure 1E). Cardiac magnetic resonance imaging confirmed the TTE findings and showed endocardial late gadolinium enhancement in the LV anterior wall and apex, suggestive of fibrosis and obliteration of the LV apex consistent with thrombus (Figure 1F; Movie II in the Data Supplement). Percutaneous endomyocardial biopsy of the right ventricle only revealed slight endocardial and interstitial fibrin deposit.Download figureDownload PowerPointFigure 1. Transthoracic echocardiography at admission.A, Apical 4-chamber view showing prominent obliteration of the left ventricular (LV) apex by a thrombus (arrows). B, Pulsed-wave Doppler recording of mitral inflow consistent with a restrictive diastolic pattern. C, Tissue Doppler recording of the decreased lateral mitral annular velocity. D, Continuous-wave Doppler recording of tricuspid regurgitation with a velocity of 4.19 m/s. E, Speckle-tracking echocardiography showing decreased LV global longitudinal strain. F, Cardiac magnetic resonance image showing a thrombus (arrow) and slight endocardial fibrosis in the apex. LA indicates left atrium; and RV, right ventricle.The patient was immediately treated with a corticosteroid, warfarin, furosemide, spironolactone, salazosulfapyridine, cyclophosphamide, and anakinra. The patient had New York Heart Association class III functional capacity at the 1-month follow-up, and the laboratory test results were as follows: CRP concentration, 30.71 mg/L; erythrocyte sedimentation rate, 37 mm/h; D-dimer level, 1.82 μg/mL; and NT-proBNP level, 2561 pg/mL. TTE showed decreased thrombus size (3.7×1.6 cm) and degree of obliteration of the LV apex (Movie III in the Data Supplement), mild-to-moderate mitral and tricuspid regurgitation, and significant reduction in the estimated systolic pulmonary artery pressure, but the same restrictive diastolic pattern (grade III) was observed.At the 3-month follow-up, she had New York Heart Association class I function capacity and a 28-joint disease activity score of 1.8. The results of the follow-up blood analysis were as follows: CRP concentration, 8.5 mg/L; erythrocyte sedimentation rate, 7.1 mm/h; D-dimer level, 1.61 μg/mL; and NT-proBNP level, 88 pg/mL. Repeat TTE showed slight biatrial enlargement with mild mitral and tricuspid regurgitation (the tricuspid regurgitation velocity was <2 m/s) and a significant improvement in diastolic function (grade I). In addition, the global longitudinal strain significantly increased to -14.5% (Figure 2; Movie IV in the Data Supplement). The patient did well and periodically underwent follow-up examinations.Download figureDownload PowerPointFigure 2. Transthoracic echocardiography after the 3-month follow-up.A, Apical 4-chamber view showing that the thrombus has disappeared. B, Pulsed-wave Doppler recording showing that the restrictive diastolic pattern of mitral inflow has disappeared. C, Tissue Doppler recording showing higher lateral mitral annular velocity than that at admission. D, Speckle-tracking echocardiography showing higher left ventricular (LV) global longitudinal strain than that at admission. LA indicates left atrium; and RV, right ventricle.DiscussionRA is a chronic inflammatory autoimmune disease characterized by progressive and disabling symmetrical polyarthritis with specific autoantibodies. The increased incidence of cardiovascular disease in patients with RA is well recognized.1 In addition to the high incidence of congestive heart failure, prothrombotic state due to coagulation and fibrinolytic system abnormalities, changes in platelet reactivity, and endothelial dysfunction have been consistently reported in patients with RA.2 In this patient, fibrinolytic system abnormalities resulting from RA were possibly responsible for the thrombus formation in LV.Pervious study has suggested that a high prevalence of LV diastolic dysfunction in patients with RA is attributed to myocardial inflammation resulting from immune dysregulation; a 28-joint disease activity score of ≥2.6 was found to be independently associated with LV diastolic dysfunction.3 In our patient, despite the preserved ejection fraction, subclinical systolic myocardial dysfunction was detected by speckle-tracking echocardiography in addition to the restrictive diastolic pattern, and the myocardial abnormalities may be explained by the active RA.3The echocardiographic and clinical manifestations in our patient were similar to the cardiac involvement in hypereosinophilic syndrome, which was formerly known as Loeffler endocarditis. However, hypereosinophilic syndrome is characterized by hypereosinophilia (eosinophil count, >1.5×109) lasting for at least 6 months or evidence of eosinophil-mediated organ damage in the absence of hypereosinophilia.4 Laboratory findings and endomyocardial biopsy did not support the diagnosis of hypereosinophilic syndrome in our patient.Echocardiography provides accurate and reliable estimation of cardiac structure and function without exposure to harmful ionizing radiation, thereby playing an important role in the diagnosis and management of cardiac involvement in patients with RA. Moreover, speckle-tracking echocardiography can detect early systolic myocardial dysfunction, which is associated with the severity of RA and provides additional prognostic information on patients with RA. Therefore, there is reasonable evidence to support the use of echocardiography in the early stages of RA.In conclusion, we present a case of a 58-year-old woman with active RA who was diagnosed with heart failure with preserved ejection fraction complicated with a large LV thrombus. She responded promptly to steroid, antithrombotic, and anti-inflammation therapy with significant alleviation in symptoms and cardiac function. As the cardiac involvement is a preventable and treatable condition in the early stage, physicians should be more vigilant regarding cardiac complications, and echocardiography should be performed in the early stages of RA to ensure timely commencement of interventions, which may further improve patient outcomes.Sources of FundingThis study was supported by the National Natural Science Foundation of China (81701699), the China Postdoctoral Foundation (2019m651172), and the Doctoral Initiate Foundation of Liaoning (20170520053).DisclosuresNone.Footnotes*Drs Liu and Sun contributed equally to this work.The Data Supplement is available at https://www.ahajournals.org/doi/suppl/10.1161/CIRCIMAGING.119.010222.Limin Zhang, MD, Department of Cardiovascular Ultrasound, First Hospital of China Medical University, 155 Nanjing Bei St, Shenyang, Liaoning 110001, China. Email [email protected]comReferences1. Maradit-Kremers H, Crowson CS, Nicola PJ, Ballman KV, Roger VL, Jacobsen SJ, Gabriel SE. Increased unrecognized coronary heart disease and sudden deaths in rheumatoid arthritis: a population-based cohort study.Arthritis Rheum. 2005; 52:402–411. doi: 10.1002/art.20853CrossrefMedlineGoogle Scholar2. Barbati C, Vomero M, Colasanti T, Ceccarelli F, Marcosano M, Miranda F, Novelli L, Pecani A, Perricone C, Spinelli FR, et al. Microparticles and autophagy: a new frontier in the understanding of atherosclerosis in rheumatoid arthritis.Immunol Res. 2018; 66:655–662. doi: 10.1007/s12026-018-9053-0CrossrefMedlineGoogle Scholar3. Liang KP, Myasoedova E, Crowson CS, Davis JM, Roger VL, Karon BL, Borgeson DD, Therneau TM, Rodeheffer RJ, Gabriel SE. Increased prevalence of diastolic dysfunction in rheumatoid arthritis.Ann Rheum Dis. 2010; 69:1665–1670. doi: 10.1136/ard.2009.124362CrossrefMedlineGoogle Scholar4. Lefèvre G, Ackermann F, Kahn JE. Hypereosinophilia with asthma and systemic (non-vasculitic) manifestations: eosinophilic granulomatosis with polyangiitis or hypereosinophilic syndrome?Autoimmun Rev. 2017; 16:208–209. doi: 10.1016/j.autrev.2016.11.001CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kim S, Park H, Jeon J, Arsanjani R, Heo R, Lee S, Moon I, Yoo S and Chang H (2022) Fully automated quantification of cardiac chamber and function assessment in 2-D echocardiography: clinical feasibility of deep learning-based algorithms, The International Journal of Cardiovascular Imaging, 10.1007/s10554-021-02482-y, 38:5, (1047-1059), Online publication date: 1-May-2022. June 2020Vol 13, Issue 6 Advertisement Article InformationMetrics © 2020 American Heart Association, Inc.https://doi.org/10.1161/CIRCIMAGING.119.010222PMID: 32460530 Originally publishedMay 28, 2020 Keywordswrist jointmiddle agedhumansblood pressureNew YorkPDF download Advertisement SubjectsEchocardiographyFibrosisHeart FailureInflammationUltrasound