Lambl’s excrescences and a review of therapeutic strategies

Abstract

Background: Lambl’s excrescences (LEx) are thin, filiform structures that arise on the lines of closure of heart valves. Although rare, we have come across various case reports in the literature describing thromboembolic events associated with LEx. We report the case of a 63-year-old female who presented with TIA-like symptoms and was found to have a LEx on the aortic side of native aortic valve. We conducted a comprehensive literature review with emphasis on different therapeutic strategies utilized to provide insight for future encounters.Case presentation: A 63-year-old female with a past medical history significant for hypertension and hyperlipidemia presented to the emergency room with symptoms of dysarthria and unsteady gait. While in the hospital, the patient returned to her baseline gait and speech without intervention. Work-up for including computed tomography of the head, magnetic resonance imaging, and carotid doppler, as well as prolonged telemetry monitoring was negative. A transthoracic echocardiogram showed a 0.81 cm linear echodensity attached to the aortic side of the aortic valve, highly suggestive of LEx that was later confirmed on transesophageal echocardiogram. Patient was placed on clopidogrel alone for antiplatelet therapy due to an aspirin allergy and she was subsequently discharged home.Discussion: No standard management for LEx currently exists. We aim to add to the evidence of effective management and explore the literature of patients who have experienced TIA/CVA symptoms secondary to LEx.

Lambl’s Excrescences: Current Diagnosis and Management

“…It is reasonable to offer surgical valve replacement after second CVA related to LE as the recurrence rate of CVA is high [15]. In a patient with poor medical compliance, surgical excision and valve replacement may be a better option for TIA/CVA symptoms secondary to LE, given the bleeding risk on antiplatelet/anticoagulation therapy [21]. A summary of the current practices in the management of LE is schematically represented in Figure 1.…”

Lambl’s Excrescences in Congenital Heart Disease and Other Clinical Situations: A Series of 17 Cases

“…In subsequent pathologic series of normal valves, a 70% to 90% prevalence of LEx was reported, predominantly on the MV (70% to 85%), followed by the AV (62% to 90%) and the right-sided valves (8% to 20%). 9 Recently, Osorio et al 10 analyzed 33 cases of LEx, and reported the affected valve was AV in 75% (25/33), followed by MV in 17% (6/33) and pulmonary valve in 2.8% (1/33). Salah et al 11 analyzed the cases published from 1981 to 2018; in that series, the affected valve was AV in 89% and MV in 7%, with one case in the pulmonary valve.…”

Imaging in Infective Endocarditis—Current Opinions and Trends in Cardiac Computed Tomography

“…Differential diagnosis of vegetations includes thrombus, hypoattenuated leaflet thickening (HALT), fibroelastoma, Lambl's excrescencies, and non-bacterial endocarditis (NBTE) [58][59][60][61][62]. Thrombus is irregular soft tissue lesion attached to the leaflets, sewing ring, or both, predominantly to the side of higher pressure [58].…”

“…Fibroelastoma are pedunculated lesions attached to the leaflet, rarely causing valve dysfunction or emboli due to thrombi adherence or disintegration [60]. Lambl's excrescences are thinner filiform lesions that arise in commissural valve zones [61]. NBTE appears as small irregular lesions, commonly affects left-sided valves and is associated with malignancy, hypercoagulable states, and autoimmune disease (Libman-Sacks endocarditis).…”