Transthoracic versus transesophageal echocardiography for detection of Libman-Sacks endocarditis: a randomized controlled study.

OBJECTIVE: Libman-Sacks endocarditis in patients with systemic lupus erythematosus (SLE) is complicated with thromboembolism, severe valve regurgitation, need for high-risk valve surgery, or death. Transesophageal echocardiography (TEE) is highly accurate for detection of valvular heart disease, but there are no prospective randomized controlled series comparing transthoracic echocardiography (TTE) to TEE for detection of Libman-Sacks endocarditis.

METHODS: Eighty-one patients with SLE (73 women, 8 men) with a mean age of 39 +/- 11 years and 75 healthy volunteers (40 women, 35 men) with a mean age of 35 +/- 9 years underwent paired TTE and TEE to detect valve vegetations, thickening, or >or= moderate mitral, tricuspid, or pulmonic >or= mild aortic regurgitation. Paired TTE and TEE studies of patients and controls were randomized and interpreted by an experienced observer unaware of subjects' data.

RESULTS: Libman-Sacks endocarditis: (1) was more common in patients than in controls by both TTE and TEE (p < 0.001); and (2) was more commonly detected by TEE than by TTE (p </= 0.05); (3) TTE and TEE demonstrated poor agreement rates (kappa 0.02-0.54); and (4) considering TEE as the standard, TTE demonstrated a low sensitivity (63% overall, 11% for valve vegetations), low specificity (58%), low negative predictive value (40%), and a moderate positive predictive value (78%) for detection of Libman-Sacks endocarditis.

CONCLUSION: TEE is superior to TTE for detection of Libman-Sacks endocarditis and should be considered either as complement to a nondiagnostic TTE or as the initial test in patients with SLE with suspected cardioembolism, acute or subacute Libman-Sacks endocarditis with moderate or worse valve dysfunction, or superimposed infective endocarditis.