Double Giant Lambl's Excrescence of aortic valve causing ... - medIND

Indian J Thorac Cardiovasc Surg (Jan–March 2011) 27:36–38
DOI 10.1007/s12055-010-0062-4
CASE REPORT
Double Giant Lambl’s Excrescence of aortic valve causing
posterior circulation stroke
Vijayakumar Raju & Muralidharan Srinivasan & Chandrasekar Padmanaban &
Venkatadevanathan Muthubaskaran & Rajpal Kanaklal Abhaichand
Received: 31 October 2009 /Accepted: 21 November 2010 /Published online: 30 December 2010
# Indian Association of Cardiovascular-Thoracic Surgeons 2010
Abstract Diagnostic evaluation of embolic neurologic
events requires the consideration of cardiac causes. Lambl’s
Excrescences (LE)are filiform fronds that occur at sites of
valvular closure due to “wear and tear” (Lambl Wien Med
Wschr 6:244–247, 1856). The complex form of LE is
“giant Lambl’s Excrescences” which results from the
adherence of multiple adjacent excrescences that grow
large. We recently had young male adult who presented
with features of posterior circulation stroke (basilar) and
detected to have two separate giant Lambl’s Excrescences
on the aortic valve and treated successfully.
Keywords Aortic valve . Computed tomography . Stroke
V. Raju : M. Srinivasan (*) : C. Padmanaban : V. Muthubaskaran
Department of Cardiovascular and Thoracic Surgery,
G. Kuppuswamy Naidu Memorial Hospital,
Coimbatore, Tamilnadu, India
e-mail: drmurali@vsnl.com
V. Raju
e-mail: vijraju@hotmail.com
C. Padmanaban
e-mail: chanpad@gmail.com
V. Muthubaskaran
e-mail: Venkatvision2020@yahoo.com
R. K. Abhaichand
Department of Cardiology,
G. Kuppuswamy Naidu Memorial Hospital,
Coimbatore, Tamilnadu, India
e-mail: drrajpal@yahoo.com
Case report
44 years old male who is a chronic smoker, presented with
history of sudden onset of left sided neck pain associated
with bilateral visual disturbance in the form of blurring and
diplopia since 2 days. There was no history of cardiac
symptoms, fever, motor or sensory deficit. He was
evaluated by the neurologist at local hospital and Computed
tomography showed small infarct in the posterior watershed
area. Electrocardiogram (ECG) showed “T” wave inversion
in anterior chest leads, hence he was refered to our
cardiology department.
On evaluation his systemic blood pressure was 170/
110 mm hg and had diplopia on both eyes . Neurological
and cardiovascular examination was otherwise
normal. His basic biochemical investigations including
markers for acute coronary syndrome were within
normal limits. Chest roentgenogram revealed normal
cardiac and lung shadows. ECG showed T wave
inversion in anterior chest leads. Transthoracic echocardiogram
showed suspicious of Aortic valve mass with
mild aortic regurgitation with mild left ventricular
dysfunction. Transesophageal echocardiogram showed
17×11 mm sessile mass attached to the inferior aspect
of Right Coronary Cusp (RCC) and its base extends to
interventricular septum. An additional mass 24×10 mm
attached to the Left ventrricular aspect of Left Coronary
Cusp (LCC) (Fig. 1). No evidence of aortic stenosis or
aortic regurgitation.
Based on the above findings we assumed that his clinical
presentation was secondary to embolization of aortic valve
mass in to the posterior cerebral circulation. Conventional
coronary angiogram was deferred in the view of aortic
valve mass. 128 slice coronary computerized tomogram

Indian J Thorac Cardiovasc Surg (Jan–March 2011) 27:36–38 37
Fig. 1 TEE showing “double Giant Lambl’s excrescence” attached to
left and right coronary cusp of aortic valve
revealed normal coronary arteries. He was taken up for
excision of aortic valve tumor.
Surgery was carried via midline sternotomy and went on
Cardiopulmonary bypass by using aortic and two stage
single RA venous cannula. Left ventricle was vented
through right superior pulmonary vein. After cross clamping
the aorta, transverse aortotomy was made and heart was
arrested with osteal cardioplegia. Aortic outflow was almost
completely occluded by two separate papillomatous lesion
arising from inferior aspect of LCC and RCC and each
lesion measuring about 1.5×1.5 cm and their attachment
was extending to the Interventricular septum. Aortic surface
of the Leaflets were free. Coronary ostia was normal. Both
aortic cusps were retracted and both lesion were shaved off
from the cusps (Fig. 2). Aortic leaflets were preserved fully.
On table Transesophageal echocardiogram showed no
Fig. 2 Totally excised specimen of Lambl’s excrescence of aortic
valve without any damage to the Aortic cusps
Fig. 3 Postoperative TEE showing no residual lesion with normal
coaptation of aortic valve
residual lesion with good valve coaptation with no aortic
regurgitation (Fig. 3). He had uneventful postoperative
period. Histopathology confirmed that the lesion was Giant
Lambl’s Excrescence of aortic valve. He had persistent
diplopia and mild visual blurring, but no new neurological
deficit. He was discharged on antiplatelets. His diplopia
was disappeared in 6 weeks following surgery.
Discussion
Lambl’s excrescences were first described by Vile’m Dusan
Lambl, a Bohemian physician in 1859. Lambl described
small filiform projections(Lambl’s excrescences) on the
cusps of aortic valves in 2% of 1,000 autopsies [1]. They
may found without any other evidence of cardiac disease.
They are more commonly seen on the mitral valve than on
the aortic valve, typically near the closure line of mitral
valve. They originate as small thrombi on endocardial
surfaces where valve margins make contact. These are the
sites of minor endothelial damage, due to wear and tear [2].
In atrioventricular valves, LE are found at the site of valve
closure. In semilunar valves, they can occur anywhere on
the valve. These lesions are broder and multiple.
The Complex form of LE is “giant LE”, which results
from the adherence of multiple adjacent excrescences that
grow large [3, 4]. LE are a fairly rare disease entity. Giant
LE are still very rare entity. Only one case report
mentioning about Giant LE presenting with embolus to
the popliteal artery embolus [5]. No literature is available
about “double Giant LE” in aortic valve for best our
knowledge .
Their papillary structure, with loose, friable projections,
results in a high tendency for embolism. Tumor

38 Indian J Thorac Cardiovasc Surg (Jan–March 2011) 27:36–38
fragments often embolize to the coronary, systemic, or
cerebral arterial systems. Quinson ‘s group described a
case of LE causing obstruction of right coronary ostium
in a 64 year old women with angina [6]. Earlier reports
have mentioned that LE are usually an uncommon cause
of cerebral embolism [7]. No literature is available about
LE causing posterior circulation stroke from best of our
knowledge.
Transesophageal Echocardiogram(TEE) is very useful in
identifying valvular strands in patients with suspected
cardiogenic embolic stroke. . Valve strands were reported
in 39%of elderly patients who had TEE for suspected
cardiogenic embolic stroke [8]. The distinction between
papillary fibroelastoma and Lambl’s excrescence was
particularly difficult. Papillary Fibroelastoma (PFE) typically
appears on echocardiography as a small pedunculated,
homogenous, well-demonstrated mobile mass attached by a
small stalk. Although these findings may be applied to the
Lambl’s excrescence, the stalk of papillary fibroelastoma
has a broader base than LE.
Histologically, LEs are avascular, and often acellular
with a hyaline core. Most patients with LE are asympotamatic.
However aortic valve lesions can break and
embolize. TEE should be included as essential part of
evaluation of any stroke. Any features of distal emboliza-
tion, is an indication for surgical removal. Asymptomatic
patients should be monitored very closely.
References
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