Cardiology Research and Practice Endomyocardial biopsy for attempted deﬁnitive histo- logical diagnosis despite the risks and potentially low yield is still widely recommended [8], and at least ﬁve right ventricular samples have been recommended [18]. It is important to say that biopsy is mainly used to diﬀerentiate between SLE myocarditis and antimalarial-induced damage, and in a previously published case series of 58 patients with endomyocardial biopsies in SLE-related cardiomyopathy, 38% percent were diagnostic of lupus-induced damage, 22% of drug related damage, and 29% nonspeciﬁc. Histological features of SLE cardiomyopathy may be nonspeciﬁc to some degree, but there are some important typical features to be aware of which include initially inﬂam- matory cell inﬁltrates, for example CD 68 macrophages, which can be identiﬁed using immunohistochemistry [8]. As the disease advances, there is myocardial necrosis, ﬁbrotic replacement, and scarring, all features seen in our patient’s histology. In the end, the variable diagnostic yield nature of endo- myocardial combined with the sometimes nonspeciﬁc nature of the disease means that diagnosis must be a balanced clin- ical decision taking into account the history, examination, immunology, imaging, and, if possible, histology. 8.5. Treatment of Cardiac SLE 8.5.1. Medical Management. While SLE causes a wide range of cardiovascular diseases, the complication should be dealt with in the standard fashion, that is, angiotensin-converting enzyme inhibitors, beta-blocker for left ventricular impair- ment, and coronary stenting for stenoses. Reviewing the literature, the most common immuno- suppressive treatment choice for acute ﬂares seems to be high-dose steroids followed by pulsed cyclophosphamide [19, 20], which is a similar regimen to other acute SLE crises such as lupus nephritis. Intravenous immunoglobulins [21] have been used in one or two case reports with some success, but the overwhelming treatment goal should be rapid immunosuppression whatever the method. After treatment of the acute phase, there seems to be no real consensus on what is the appropriate long-term drug choice, with steroids and azathioprine among the choices [22]. When there is secondary antiphospholipid syndrome, a recent consensus statement suggests warfarin in the case of symptomatic valvulopathy, thrombus, and pulmonary hypertension only and not as a routine [23]. 8.5.2. Resynchronisation Therapy. One potential therapeutic option in advanced stages of heart failure regardless of the source is cardiac resynchronisation therapy (CRT). There have been several reports illustrating the successful use of cardiac resynchronization in patients with SLE and resistant cardiomyopathy [24, 25]. As yet there is much discus- sion about which patients beneﬁt from resynchronisation, but while there is not complete agreement about patient selection, most groups agree that those with ventricular dyssynchrony, reduced ejection fraction, and symptomatic 5 New York classiﬁcation 2 to 3 heart failure beneﬁt most [26]. One interesting potential unexpected beneﬁt of CRT is that it has been shown to reduce inﬂammatory cytokines, possibly reducing the inﬂammatory process [27]. Overall SLE myocarditis has a much poorer outcome when compared to primary myocarditis [28], and this illustrates the need for prompt diagnosis and early aggressive treatment, which can result in improvement of myocardial function back to normal [19]. 8.6. Cardiac Transplant in SLE. Our search results revealed a total of 7 cases of cardiac transplant in SLE for a variety of reasons, 4 were for pulmonary hypertension, 1 for post- mitral valve replacement heart failure, 1 for cardiac failure following prolonged infective endocarditis in a patient with SLE, and 1 patient with myocarditis and heart failure [29, 30]. Transplant was successful in 5 of the seven cases with followup through both cohorts being at least 14 months [29, 30], and in the case of the patient with myocarditis 18 months with no signs of recurrence on endomyocardial biopsy and EF of 50–60% [30]. While these are small numbers, they do, at least, give some guidance to physicians that in refractory cases trans- plant is an option and that there have been positive results in the small number of patients that have been operated on. The ideal postoperative combination of antirejection treatment is normally decided by the local transplant team involved, but in the series, that we reviewed that cyclosporin, prednisolone, and azathioprine in combination was the most widely used regimen [30, 31]. 9. Conclusions Cardiac SLE is a complex disease with multiple possible pathological processes that requires prompt investigation and prompt treatment, otherwise the damage is unrecover- able as proven in our patient. References [1] M. Apte, G. McGwin Jr., L. M. Vila´, R. A. Kaslow, G. S. Alarco´ n, and J. D. Reveille, “Associated factors and impact of myocarditis in patients with SLE from LUMINA, a multiethnic US cohort,” Rheumatology, vol. 47, no. 3, pp. 362–367, 2008. [2] C. Cevik, K. Nugent, A. Perez-Verdia, and R. D. Fish, “Prophy- lactic implantation of cardioverter deﬁbrillators in idiopathic nonischemic cardiomyopathy for the primary prevention of death: a narrative review,” Clinical Cardiology, vol. 33, no. 5, pp. 254–260, 2010. [3] S. Bernatsky, L. Joseph, C. A. Pineau, R. Tamblyn, D. E. Feldman, and A. E. Clarke, “A population-based assessment of systemic lupus erythematosus incidence and prevalence— results and implications of using administrative data for epidemiological studies,” Rheumatology, vol. 46, no. 12, pp. 1814–1818, 2007. [4] A. Rasmussen, S. Sevier, J. A. Kelly et al., “The lupus family registry and repository,” Rheumatology, vol. 50, no. 1, pp. 47– 59, 2011. [5] S. Busteed, P. Sparrow, C. Molloy, and M. G. Molloy, “Myocarditis as a prognostic indicator in systemic lupus