What is the management of Lambl's excrescence?

Management of Lambl's Excrescences

For patients with Lambl's excrescences who have experienced two or more cerebrovascular accidents, surgical excision of the excrescences is recommended as the definitive treatment. 1, 2

What are Lambl's Excrescences?

Lambl's excrescences are filiform (thread-like) fronds that occur at sites of valve closure. They:

• Form as small thrombi on endocardial surfaces where valve margins contact
• Are considered normal variants resulting from valvular wear and tear
• Can be found on any cardiac valve but most commonly on the aortic valve
• May be difficult to distinguish from other cardiac structures such as fibroelastomas, thrombi, or vegetations 3

Diagnosis

Transesophageal echocardiography (TEE) is the diagnostic method of choice:

• TEE has higher sensitivity than transthoracic echocardiography (TTE) for detecting Lambl's excrescences
• Should be included in the diagnostic assessment of all patients with unexplained stroke 1
• May produce false-positive results as Lambl's excrescences can be indistinguishable from previous scarring, severe myxomatous change, or other normal structures 3

Management Algorithm

1. Asymptomatic Patients with Incidental Finding

• Close monitoring without specific intervention
• Regular follow-up with clinical evaluation 1, 2

2. Patients with First Cerebrovascular Event

• Antiplatelet therapy (e.g., aspirin) is recommended
• Consider TEE follow-up at 3-6 months to monitor for changes 4, 5

3. Patients with Recurrent Cerebrovascular Events

• Surgical excision of the excrescences is recommended
• Operative removal should be performed via open heart surgery with débridement of the excrescences 1, 2

4. Patients with Other Cardiac Conditions Requiring Surgery

• Concomitant surgical excision of Lambl's excrescences should be performed during the planned cardiac surgery 2

Evidence-Based Recommendations

1. First Cerebrovascular Event:

   • Antiplatelet therapy is the first-line treatment
   • Close monitoring with follow-up imaging 4, 5

2. Recurrent Cerebrovascular Events:

   • Surgical intervention is indicated after two or more events
   • Anticoagulation may be considered as a bridge to surgery or for patients who are not surgical candidates 1, 2

3. Monitoring:

   • Follow-up TEE at 6 months and 1 year is reasonable for patients managed conservatively 5

Important Considerations

• Lambl's excrescences must be differentiated from other cardiac masses including fibroelastomas, vegetations, and thrombi, as management differs significantly 6
• False-positive results from TEE studies may occur as valvular abnormalities can be indistinguishable from active changes in the valves 3
• The American Heart Association guidelines recognize Lambl's excrescences as potential sources of confusion during echocardiographic evaluation for infective endocarditis 3

Common Pitfalls to Avoid

1. Misdiagnosis of Lambl's excrescences as infective endocarditis, leading to unnecessary antibiotic treatment
2. Failure to consider Lambl's excrescences in the differential diagnosis of cryptogenic stroke
3. Premature surgical intervention for asymptomatic patients with incidental findings
4. Inadequate follow-up for patients managed conservatively, potentially missing progression or complications

By following this management approach based on symptomatology and recurrence of events, clinicians can optimize outcomes for patients with Lambl's excrescences while minimizing unnecessary interventions.