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PubMed This is a summary of 21 peer-reviewed journal articles Updated
Cardiology

Diagnosing LSE: The Crucial Role of Specialized Ultrasounds

At a Glance

The gold standard for diagnosing Libman-Sacks endocarditis is a transesophageal echocardiogram (TEE). Unlike standard ultrasounds, a TEE provides the high-resolution images necessary to find the small, flat, sterile vegetations on heart valves caused by lupus or antiphospholipid syndrome.

Diagnosing Libman-Sacks Endocarditis (LSE) is a specialized process that requires more than a standard heart ultrasound. Because the growths (vegetations) in LSE are often small, flat, and hidden in hard-to-see areas of the heart, a high-resolution approach is essential to ensure they are not missed [1][2]. Return to the Home Page for an overview.

Why the “Standard” Ultrasound Is Not Enough

Most patients first receive a Transthoracic Echocardiogram (TTE), where an ultrasound probe is placed on the chest. While TTE is a great first step, it often lacks the detail needed to find LSE vegetations [1].

  • Distance: In a TTE, the ultrasound waves must travel through skin, muscle, and bone to reach the heart.
  • Resolution: Small or flat growths (often less than 5mm to 10mm) can be invisible on a standard TTE [3].
  • Hidden Locations: LSE growths often form on the underside of valves or in corners of the heart that the TTE probe cannot easily “see” [4].

The Power of Transesophageal Echocardiography (TEE)

The “gold standard” for identifying LSE is the Transesophageal Echocardiogram (TEE) [1][3]. During this procedure, you are sedated, and a thin tube with a small ultrasound probe is passed down your esophagus (the food pipe), which sits directly behind your heart [1].

  • Clearer View: Because the probe is only millimeters away from the heart, the images are incredibly sharp and detailed [3].
  • 3D Imaging: Modern TEE often uses 3D-TEE technology, which creates a realistic, three-dimensional reconstruction of your heart valves [5][6]. This helps doctors see the exact shape and size of vegetations and distinguishes them from normal heart structures [7][8].

What Doctors Look For on TEE

On a TEE, Libman-Sacks vegetations have specific characteristics that help your care team identify them:

  • Sessile Shape: Unlike the “swinging” or finger-like growths often seen in bacterial infections, LSE vegetations are usually sessile, meaning they are broad-based and sit flat against the valve [4].
  • Unique Locations: They are frequently found on both sides of the mitral or aortic valves, or even on the walls of the heart chambers themselves [9][10].
  • Valve Thickening: Beyond just seeing growths, TEE can detect subtle thickening or scarring of the valve tissue, which is a common sign of long-term lupus heart disease [11][12].

Complementary Tests for a Full Picture

A diagnosis of LSE is rarely based on heart imaging alone. Your doctors will use several other tools to understand how the condition is affecting your body:

  1. Brain MRI: Because LSE carries a high risk of tiny, “silent” blood clots traveling to the brain, a brain MRI is often performed to look for signs of small strokes or “lacunar” infarctions that you might not even feel [13][14].
  2. Blood Markers: Your doctor will check for active markers of Systemic Lupus Erythematosus (SLE) and Antiphospholipid Syndrome (APS), such as anti-dsDNA, lupus anticoagulant, and anti-cardiolipin antibodies [15][16]. High levels of these antibodies are often linked to the formation of these heart valve growths [17][18].
  3. Blood Cultures: To be absolutely sure the growths are not caused by a bacterial infection, multiple blood cultures will be taken to confirm they are sterile [19].

By combining these high-tech images with detailed blood work and brain scans, your medical team can build a complete map of your health and create the best plan to protect your heart and brain [20][21].

Common questions in this guide

Why do I need a TEE if my standard heart ultrasound (TTE) was normal?
A standard ultrasound on the chest often lacks the detail to see the small, flat growths typical of Libman-Sacks endocarditis. A TEE involves a small probe placed in your esophagus, directly behind your heart, providing the sharp images needed to find hidden growths.
What do Libman-Sacks vegetations look like on an ultrasound?
Unlike bacterial infections that cause finger-like growths, Libman-Sacks vegetations are usually sessile. This means they are broad-based and sit flat against the heart valve. They are often located on both sides of the mitral or aortic valves.
Why might my doctor order a brain MRI if I have a heart valve issue?
Libman-Sacks endocarditis carries a high risk of small blood clots breaking off and traveling to the brain. A brain MRI helps doctors detect tiny, silent strokes that you might not even feel but that require medical management.
How do blood tests help diagnose Libman-Sacks endocarditis?
Doctors check your blood for markers of lupus (SLE) and antiphospholipid syndrome (APS), which are known to cause these heart valve growths. They also run blood cultures to ensure the growths are sterile and not caused by a bacterial infection.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Why do you recommend a TEE for me if my standard heart ultrasound (TTE) already came back normal?
  2. 2.If vegetations are found, what specific features (like size, shape, or location) tell you they are from my lupus rather than an infection?
  3. 3.Can you use 3D TEE to get a better view of my heart valves? How does that change the accuracy of my diagnosis?
  4. 4.Should I also have a brain MRI to check for any 'silent' embolic events that my heart condition might have caused?
  5. 5.How do my current SLE and APS blood test results (like my antibody levels) influence the way you interpret my heart imaging?

Questions For You

Tap a prompt to share your answer — we'll use it plus this page's context to start a tailored conversation.

References

References (21)
  1. 1

    A Contemporary 20-Year Cleveland Clinic Experience of Nonbacterial Thrombotic Endocarditis: Etiology, Echocardiographic Imaging, Management, and Outcomes.

    Zmaili MA, Alzubi JM, Kocyigit D, et al.

    The American journal of medicine 2021; (134(3)):361-369 doi:10.1016/j.amjmed.2020.06.047.

    PMID: 32827467
  2. 2

    The impact of Libman-sacks endocarditis on inpatient outcomes with systemic lupus erythematosus: A retrospective study.

    Alfatlawi H, Alharbi A, Shah M, et al.

    Lupus 2024; (33(7)):693-699 doi:10.1177/09612033241243179.

    PMID: 38564733
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    Non-Bacterial Thrombotic Endocarditis as a Cause of Cryptogenic Stroke in Malignancy.

    Ilyas S, Lang W, Belani N, Stockwell P

    Rhode Island medical journal (2013) 2021; (104(2)):63-66.

    PMID: 33648323
  4. 4

    Multivalvular involvement associated with Libman-Sacks endocarditis detected by multimodality imaging: A case report.

    Bui STT, Nguyen PH, Nguyen TN, et al.

    Frontiers in cardiovascular medicine 2023; (10()):1117711 doi:10.3389/fcvm.2023.1117711.

    PMID: 37063968
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    Novel 3D versus traditional transesophageal echocardiography techniques: Defining differences in the diagnosis of infective endocarditis.

    Tomoaia R, Beyer RȘ, Dădârlat-Pop A, et al.

    European journal of clinical investigation 2024; (54(2)):e14103 doi:10.1111/eci.14103.

    PMID: 37815038
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    An update on intraoperative three-dimensional transesophageal echocardiography.

    Rong LQ

    Journal of thoracic disease 2017; (9(Suppl 4)):S271-S282 doi:10.21037/jtd.2017.03.123.

    PMID: 28540070
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    Papillary Fibroelastoma of the Aortic Root Causing Intermittent Coronary Ostial Obstruction: The Diagnostic Power of 3D Transesophageal Echocardiography.

    Bečić T, Perković-Avelini R, Fabijanić D

    Diagnostics (Basel, Switzerland) 2026; (16(1)) doi:10.3390/diagnostics16010168.

    PMID: 41515663
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    Role of 3D Echocardiography in Cardiac Surgery: Strengths and Limitations.

    Turton EW, Ender J

    Current anesthesiology reports 2017; (7(3)):291-298 doi:10.1007/s40140-017-0226-5.

    PMID: 28890667
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    Mitral valve 'kissing lesion' in Libman-Sacks endocarditis.

    Sadeghpour A, Pourafkari L, Nader ND

    QJM : monthly journal of the Association of Physicians 2021; (114(5)):338 doi:10.1093/qjmed/hcaa342.

    PMID: 33401301
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    Libman-Sacks Endocarditis in a Patient With Antiphospholipid Syndrome.

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    The Annals of thoracic surgery 2016; (102(1)):e31-2.

    PMID: 27343524
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    Libman-Sacks Endocarditis Involving a Bioprosthesis in the Aortic Valve Position in Systemic Lupus Erythematosus.

    Roberts WC, Lee AY, Lander SR, et al.

    The American journal of cardiology 2019; (124(2)):316-318 doi:10.1016/j.amjcard.2019.04.031.

    PMID: 31133276
  12. 12

    Aortic valve surgery for aortic regurgitation caused by Libman-Sacks endocarditis in a patient with primary antiphospholipid syndrome: a case report.

    Le Ho Y, Ahmad Zaidi NA, Salleh A, Abdul Kareem BA

    Journal of cardiothoracic surgery 2021; (16(1)):92 doi:10.1186/s13019-021-01458-2.

    PMID: 33865405
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    Non-Bacterial Thrombotic Endocarditis in a Patient with Rheumatoid Arthritis.

    Choi JH, Park JE, Kim JY, Kang T

    Korean circulation journal 2016; (46(3)):425-8 doi:10.4070/kcj.2016.46.3.425.

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    Neurologic complications of nonbacterial thrombotic endocarditis.

    Dafer RM

    Handbook of clinical neurology 2021; (177()):135-141 doi:10.1016/B978-0-12-819814-8.00013-5.

    PMID: 33632431
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    Cardiac Involvement in Systemic Lupus Erythematosus.

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    Reviews in cardiovascular medicine 2025; (26(11)):42760 doi:10.31083/RCM42760.

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    Impact of antiphospholipid antibodies on heart valve involvements in systemic lupus erythematosus: based on CSTAR cohort.

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    Lupus science & medicine 2025; (12(1)) doi:10.1136/lupus-2025-001674.

    PMID: 40541268
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    Impact of antiphospholipid antibodies on cardiac valve lesions in systemic lupus erythematosus: a systematic review and meta-analysis.

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    Clinical and experimental medicine 2024; (24(1)):147 doi:10.1007/s10238-024-01406-z.

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    Clinical characteristics and long-term outcomes of Libman-Sacks endocarditis in patients with systemic lupus erythematosus.

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    PMID: 32536317
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    Case report of culture-negative endocarditis in lupus nephritis.

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This page explains diagnostic tests for Libman-Sacks endocarditis for educational purposes only. Always consult your cardiologist or rheumatologist for medical advice and to help interpret your specific imaging and blood test results.

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