International Journal of Cardiology 127 (2008) e78 – e79 www.elsevier.com/locate/ijcard
Letter to the Editor
Aortic regurgitation associated with rheumatoid arthritis: A case report Manabu Itoh a,⁎, Masaru Yoshikai a , Hiroyuki Ohnishi a , Ryo Noguchi a , Koji Irie b a
Department of Cardiovascular Surgery, Shin-Koga Hospital, Kurume, Japan b Department of Clinical Pathology, Shin-Koga Hospital, Kurume, Japan Received 17 January 2007; accepted 4 April 2007 Available online 20 June 2007
Keywords: Rheumatoid arthritis; Aortic regurgitation; Aortic valve replacement
We herein report a rare case of aortic regurgitation (AR) associated with rheumatoid arthritis (RA). A 71-year-old female patient with a history of hypertension for 6 years had started steroid medication for the treatment of RA. The dosage of oral prednisolone had been gradually reduced over the following year. The patient presented with paroxysmal nocturnal dyspnea 2 days after the discontinuation of prednisolone. On arrival, the pulse pressure was 140 mm Hg, with a blood pressure of 190/50 mm Hg. The chest X-ray demonstrated marked pulmonary congestion and cardiomegaly with a cardio-thoracic ratio of 55%. An electrocardiogram showed sinus tachycardia and a left ventricular hypertrophy. Mechanical ventilation was required for orthopnea, and medical treatment for acute heart failure was initiated. The blood test findings were as follows: WBC: 8300/μl, CRP: b 0.30 mg/dl, and BNP: 843 pg/ml. An echocardiography, performed 8 days after the admission when the symptoms of acute heart failure had subsided, demonstrated thickening of the aortic valve, causing poor coaptation of the cusps, thus resulting to grade IV AR, and grade I mitral regurgitation (MR). The left ventricular (LV) function had improved with an ejection fraction of 72%, although the LV chamber was slightly dilated. At surgery, the aortic valve showed thickening and shortening of the three cusps (Fig. 1). An aortic valve replacement using a bioprosthetic valve was successfully performed. A histopathological study of the resected aortic valve indicated calcification and mucous degeneration of the cusps. The infiltration of the lymphocytes and plasma cells showing ⁎ Corresponding author. Department of Cardiovascular Surgery, ShinKoga Hospital, 120 Tenjin-cho, Kurume, Fukuoka 830-8577, Japan. Tel.: +81 942 38 2222; fax: +81 942 38 2248. E-mail address:
[email protected] (M. Itoh). 0167-5273/$ - see front matter © 2007 Published by Elsevier Ireland Ltd. doi:10.1016/j.ijcard.2007.04.053
non-specific inflammation was observed around the calcified lesion (Fig. 2). The so called “rheumatoid nodules” were not observed. The patient recovered well after the operation. A postoperative echocardiography demonstrated an improvement of the LV dilatation and disappearance of the MR. The cardiac lesions associated with RA rarely cause symptomatic heart disease, and seldom become subject to treatment [1]. In a report of autopsied cases of RA, 5% of the cases had valvular heart disease showing typical rheumatoid nodules, and valvular heart disease with non-specific inflammation was observed in up to 75% of the cases [2]. Valvular lesions are more often found in the mitral valves, followed by the aoric valves, the tricuspid valves, and the pulmonary valves; however, the aortic valve lesions predominantly cause symptomatic heart disease [3]. The affected valves associated with RA mainly tend to cause regurgitation, in comparison to
Fig. 1. Resected aortic valve showing thickening and shortening of the three cusps.
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probably occurred after the healing process of the valvulitis, caused the AR. Valvulitis in RA often progresses acutely, resulting in severe acute heart failure. In fact, many of the reported surgical cases of AR presented with acute onset of heart failure [5,6]. Cardiovascular disease greatly affects the prognosis of patients with RA; hence, careful follow-up, including periodic echocardiography, should be required so as not to overlook the valvular lesions. References
Fig. 2. Histological examination showing infiltration of the lymphocytes and the plasma cells (H&E).
the valves affected by rheumatic fever which often result in stenosis. This difference can be explained by the fact that rheumatic fever causes commissural fusions due to the inflammation involving all layers of the valve, while RA causes degeneration such as valvular thickening and shortening due to the inflammation only in the deep layer of the valve [4]. In the case presented herein, the cusp shortening, which
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