Löffler endocarditis: a rare cause of acute cardiac failure

Abstract

We describe a patient with acute cardiogenic shock due to cardiac involvement in idiopathic hypereosinophilic syndrome (Löffler endocarditis). At the echocardiography, there was a huge mass in the left ventricular cavity, resulting in inflow- and outflow tract obstruction. The posterior leaflet of the mitral valve apparatus was completely embedded in a big (organized) thrombus mass. The patient was treated with high dose corticosteroids, however without effect. Partial remission was achieved after treatment with hydroxycarbamide. He was also treated with anticoagulants and high dose beta-blockers. The patient’s condition improved remarkably after correction of the mitral valve insufficiency by a mitral valve bioprosthesis.

Usefulness of three‐dimensional echocardiography in the assessment of valvular involvement in Loeffler endocarditis

“…We present a patient with Loeffler endocarditis in whom 3DTTE and 3DTEE were useful in assessing the four cardiac valves. We also summarize in tabular form the clinical and diagnostic features, prognosis, and management of HES as described in the literature (Tables ) …”

“…The tricuspid (TV) and pulmonary (PV) valves appeared structurally normal, with trivial tricuspid regurgitation (TR) and trivial pulmonary regurgitation (PR) present. There was a mild thickening of the aortic T A B L E 3 Loeffler endocarditis: Echocardiographic findings Ventricles • 2D STE may show reduced GLS (≤17%) at very early stage of LV endomyocardial dysfunction before other echo findings 8 • Endocardial thickening,most commonly at apices and LV posterior wall, may show areas of calcification 9 • Localized, echo dense areas in endocardium due to fibrosis from abnormal collagen deposition (apices, inflow tracts, and LV posterior wall especially basal segment at MV level) • Restrictive cardiomyopathy with restrictive pattern diastolic dysfunction may result from endocardial thickening • LV systolic function normal initially but may decrease later • LV and/or RV apical thrombi that may extend to the inflow tracts and MV/TV annuli 10,11 • Small ventricular cavities due to endocardial thickening and mural thrombi 12 • Contrast-enhanced transthoracic 3D echo shown to identify interface between apical thrombus and myocardium as a thin network of microvessels 7 Atria • LA and/or RA dilatation from restrictive cardiomyopathy and MV/TV regurgitation • A typical combination of small ventricles and large atria 9 • 3DSTE may show increased LA volumes suggesting LA remodeling and decreased reservoir function (possibly due to myocyte necrosis, extracellular matrix changes due to eosinophilic inflammation and diastolic dysfunction) 13 Valves • Thickened valves, commonly MV, next TV, less commonly AV, very rarely PV (one report only from our group) 14 • May show nodular echo densities on atrial aspect by 3D echo consistent with fibrosis (our patient) • "Vegetations" may be detected on the valves (echogenic masses on the leaflets, sometimes mobile). 10,15 • Severe regurgitation may be noted (most commonly, MR) due to scarred, restricted leaflets with noncoaptation and incomplete closure or a leaflet is included in a mural thrombus) • Restriction of valve mobility especially posterior MV and TV leaflets 9 from thickening and embedment in adjacent annular/ventricular thrombus (as in our patient) • Significant stenosis may occur but less common than regurgitation • Rupture chordae and flail MV have been reported 15 Others • Small to moderate pericardial effusion (from acute eosinophilic pericarditis, heart failure).…”

A case report of Löffler endocarditis in idiopathic hypereosinophilic syndrome: recovery is possible

“…Allogenic stem cell transplantation has also been reported to be a potentially curative therapy. It is the ultimate therapeutic measure in case of therapeutic refractoriness or intolerance to available therapies 13 . Our patient showed favourable response to corticosteroid therapy with improvement of his symptoms and reversal of the endomyocardial damage.…”

Surgical Treatment of Loffler Endocarditis in an 8-Year-Old Girl

“…At present, most of the literature reports are based on cases. Heart involvement may be present in 50% to 60% of patients, and is called Loffler endocarditis [Niemeijer 2012]. Loffler endocarditis is a serious complication of hyper eosinophilia syndrome, which is characterized by a special type of fibrotic endocarditis.…”