Multiple Lambl's excrescences with subvalvular extension, a rare cause of cryptogenic stroke: treated by port-access cardiac surgery

A Large Lambl's Excrescence Causing Embolic Stroke in a Young Patient: A Case Report and Review of Literature

Lambl's excrescences (LEs) are thin, filiform and hypermobile strands that develop at the valvular coaptation sites of the heart. Since first described in 1856 by Vilém Dušan Lambl, there has been an increasing number of reports of central and peripheral emboli arising from cardiac LEs. LEs have been linked to ischemic strokes irrespective of age and comorbidities. We report one of the youngest reported cases in literature of an embolic stroke in a 25-year-old woman caused by a LE. A comprehensive workup was performed that revealed a large aortic valve LE. The patient was discharged on dual anti-platelet therapy with outpatient cardiology follow-up for surveillance echocardiograms. We then surveyed the literature and reviewed case reports and observational studies of LEs linked to systemic emboli. We found that most LEs are present on left-sided high-pressure valves especially the ventricular aspect of the aortic valves and that most reported cases of cerebral embolism had aortic valve LEs. The management of cardioembolic stroke secondary to LEs remains unclear. LEs have not been identified as a definite etiology of cardioembolic strokes warranting the need for large-scale studies to help guide the management of cardiac LEs in the setting of ischemic stroke.

A Rare Case of Splenic Infarct Secondary to Mobile Cardiac Echodensity

Lambl's excrescences (LE) are mobile filiform lesions, mostly found on the left-sided heart valves. Histologically, they have a mesenchymal origin with a single endothelial layer. They have the potential to detach, resulting in catastrophic thromboembolic events. Their rarity often leads to them being misdiagnosed as vegetations of endocarditis with patients failing to improve on conventional therapy. A 48-year-old female with a history of hypertension presented to the Emergency Department with a one-week history of sharp left upper quadrant pain. She was vitally stable; the only lab abnormality was revealed to be a mildly elevated white cell count. CT abdomen revealed a splenic infarct involving 25% of the parenchyma. Patients had no history of abdominal trauma, coagulation disorders, exogenous estrogen use or IV drug abuse. Subsequent investigations failed to reveal any cause of hypercoagulability. An extensive cardiac workup revealed no arrhythmias, but transesophageal echocardiogram showed a mobile echo density on the ventricular side of the aortic valve attached at the coaptation zone, approximately 2.7 cm long and 0.1 cm wide, suggesting a very prominent Lambl's excrescence. In the absence of any other findings, the patient's splenic infarct was determined to be secondary to an embolic event from the aortic valve lesion. Rivaroxaban was initiated and the patient subsequently improved. Existing literature describes most LEs as being asymptomatic and discovered incidentally on echocardiograms. This case illustrates the need to develop a criterion for prompt identification of LEs and differentiating them from the vegetations of endocarditis. It also brings forth the question of prophylactic treatment of these lesions while highlighting the lack of guidelines regarding the management of embolic phenomena secondary to LE.

[A case of recurrent cerebral embolism associated with Lambl's excrescence]

A 75-year-old female had a history of prior ischemic stroke with aphasia and right hemiplegia. Magnetic resonance angiography showed left internal carotid artery occlusion. She was successfully treated with intravenous recombinant tissue plasminogen activator (IV t-PA) and underwent endovascular thrombectomy (EVT). She was diagnosed with cardioembolic stroke due to the presence of atrial fibrillation and mitral valve stenosis, and warfarin was administered. However, she experienced large vessel occlusion twice within 2 years. Upon further analysis, transesophageal echocardiography revealed a mobile hyperechoic structure on the aortic valve, which was assumed to be an embolic source. Thus, we decided to perform mitral and aortic valve replacement. The excised aortic valve structure was suggested to be an example of Lambl's excrescence, histopathologically. After surgery, the patient had no recurrence for 3 years. Several cases of ischemic stroke associated with Lambl's excrescence have been reported, but definitive guidelines for managing patients with Lambl's excrescence do not currently exist. Surgical intervention for Lambl's excrescence with recurrent ischemic events may be important for preventing further recurrence.

Lambl's Excrescences Associated With Left Frontal Ischemic Stroke: A Case Report

Lambl's excrescences (LEs) are thin filiform strands of connective tissue found on the closure line of valves. Their exact etiology is unknown, and most of them are typically asymptomatic. We present a case of a 33-year-old African American male with a history of right upper extremity weakness that resolved on its own within a few minutes. On physical examination, no focal neurologic deficit was observed. MRI brain showed a tiny curvilinear focus of restricted diffusion with subtle T2-FLAIR hyperintensity in the left frontal/insular region, indicating a recent cortical infarct. Transesophageal echocardiogram (TEE) was performed as a part of cryptogenic stroke workup, which showed LE on aortic valve leaflet tips. Our patient had elevated blood pressure (BP) on arrival; however, in LE's presence, the embolic phenomena of stroke cannot be excluded. In conclusion, this case adds to a limited number of cases with such cardioembolic phenomena, which will help in further illustrating and highlighting the need for more prospective studies to establish a causal relationship between LE and cardioembolic strokes.

Lambl's Excrescences: Current Diagnosis and Management

Lambl’s excrescences (LEs) are unusual, yet significant etiology of thromboembolism. LEs are fibrous valvular strands typically occurring at coaptation lines of the left-sided valves. These occur from wear and tear of the valves and comprise of a dense core of collagenous and elastic fibrils enclosed by endothelium. Transesophageal echocardiography (TEE) remains the gold standard in its diagnosis. Asymptomatic LEs are closely monitored, while symptomatic lesions with history of thromboembolism are managed with antiplatelet drugs or are anticoagulated. Surgery is indicated in case of recurrent thromboembolic episodes occurring while on medications.

Lambl's Excrescences and Stroke: A Scoping Study

Stroke / Cerebrovascular accident (CVA) is a leading cause of morbidity and mortality in the world. Ischemic stroke accounts for 87% of the cases, 14-30% of which is attributed to cardio-embolic stroke. Lambl's excrescences (LE) were first described in 1856 by a Bohemian physician- VilemDusanLambl and is considered a rare cause of cardioembolic stroke subtype. LE are branched filiform structures with undulating movements, 1×4-10 mm in size that are usually found on aortic and mitral valves. An atheroma from LE or LE fragments per se may embolize to cerebrovascular arterial territory causing stroke. Multiple isolated cases of stroke associated with LE have been reported in the literature. We hereby report a scoping study of the findings associated with such cases. A total of 27 cases were identified after various scientific databases including PubMed and Google scholar were searched with keywords "lambi's excrescences, stroke, cerebrovascular accidents". Data from these cases were tabulated and analyzed. The mean age at presentation was 51 ± 14.2 (± SD) years with 55% of patient younger than 55 years of age. 56% of cases were males. Transesophageal echocardiogram was more effective in detecting LE when compared to transthoracic echocardiogram. LE were most often found on aortic valve and LE related stroke was most often noted in middle cerebral artery territory. Recurrent stroke was reported in 30%. Management of these cases was highly variable and likely derived from individual experience as LE management guidelines are largely lacking. Single and dual antiplatelet therapy, anticoagulation and valvularsurgery were among the various management strategies employed. We recommend dual antiplatelet after the first episode of CVA related to LE and an antiplatelet in combination with anticoagulation after the second CVA attributed to LE. Also it is reasonable to offer valve replacement after second CVA related to LE as the reccurence rate of CVA is high. Due to rarity in LE reporting and its management a shared decision making has to be made depending on the clinical status of the patient. The formation of a worldwide registry for LE using standardized reporting criteria for the diagnosis with or without incident stroke, would help establish guidelines for the diagnosis and management of this rare, yet serious disease with increased risk of morbidity and mortality.

Acute Myocardial Infarction in a Patient with Two-Vessel Occlusion and a Large Lambl's Excrescence

A 59-year-old man underwent an echocardiography study after myocardial infarction and it showed a thin, mobile mass attached to the aortic valve. A diagnosis of Lambl's excrescence (LE) was suspected. Coronary occlusion as a consequence of embolism of LE's material could not be excluded and the patient underwent surgical excision. Histology confirmed the diagnosis; however a differential diagnosis with papillary fibroelastoma could not be established because both of these structures are histologically indistinguishable. A brief survey of the literature is presented. Evidence-based recommendations for treatment have not been established yet.

Lambl's excrescences: A case report and review of the literature

Lambl's excrescences are filamentous extensions of cardiac valves, mostly asymptomatic but rarely associated with catastrophic thromboembolic events such as acute ischemic stroke and acute coronary syndromes. Numerous case reports cited in the literature have addressed various spectrum of presentation of these syndromes and their outcomes based on therapies used. We encountered such a patient from our own experience who presented with an acute ischemic stroke with no other identifiable cause other than the Lambl's excrescences. We subsequently carried out an extensive literature search and based on our interpretation of the outcomes we decided to treat the patient to the best of our understanding. In the proceeding section we describe the case and the discussion and our rationale to treat the patient accordingly.

Lambl's Excrescence Associated with Cryptogenic Stroke: A Case Report and Literature Review

BACKGROUND

In 1856, a Bohemian physician, Vilém Dušan Lambl, first described the presence of filiform lesions in aortic valve leaflets. Lambl's excrescences are tiny filiform strands that arise on the line of valve closure, and result from valvular wear and tear. It is a rare cause of cardioembolic stroke that can be detected by transesophageal echocardiogram.

CASE REPORT

We encountered a 51-year-old, African-American woman with a history of recurrent strokes that we suspect may be the result of Lambl's excrescence. The patient was treated with dual antiplatelet therapy and was recommended to have surveillance transesophageal echocardiograms at 6 months and 1 year from the time of discharge.

CONCLUSIONS

As there are no definitive guidelines for the management of patients with Lambl's excrescences, we present a review of the current medical literature and a specific case report in an attempt to provide a better strategy for managing this condition. In our case report, we focus on the management and treatment for Lambl's excrescence because no clear evidence has been published in the literature. Our review indicates that Lambl's excrescence, despite its relative scarcity, should be considered in the differential diagnosis of a patient with cryptogenic stroke.