Thread by @MelBreggs

Inpatient Day 7:
1/ Our patient's TEE came back with an aortic valve lesion concerning for a "Lambl's Excrescence".

I had no idea what this was...so, after some research here is a brief #MedTweetorial on Lambl's Excrescences:

#Foamed #DailyInptPearl #PostItPearl

2/ First, a pre-tweetorial poll:
Which of the fllowing are patients with Lambl's Excrescence at risk for:

3/ DEFINITION:
🔷Lambl's Excrescences (LEs) are fibrous valvular strands
🔷Usually occur at coaptation lines of left-sided valves from wear/tear of valves ➡️endothelial injury
🔷Made up of collagenous and elastic fibrils
🔷Unusual, but significant source of thromboembolism (CVA)

4/ DIAGNOSIS:
🔷TEE=gold standard for dx (independent, hypermobile, undulating, strand-like structures)
🔷Most Common Location: atrial side of mitral valve (68-76%), 2nd MC: Aortic Valve on ventricular side (38-50%); right-sided lesions rare
🔷Similar incidence in men vs women

5/
HISTORY
🔷Described in 1856 by Dr. Vilem Dusan Lambl

RISK FACTORS:
✅Prior Rheumatic Heart Disease
✅Prior Endocarditis
✅pulmHTN
✅Systemic HTN
✅(Can still occur in otherwise healthy people)

6/ DIFFERENTIAL DIAGNOSIS:
🔷Imaging Artifact
🔷Vegetations
🔷Thrombi
🔷Redundant Leaflet
🔷Dissection flap
🔷Papillary fibroelastoma
🔷Myxoma
🔷Cardiac neoplasms/mets

7/ PATHOPHYSIOLOGY:
Heart Valve Closure➡️high stress (worse as we age)➡️tear or lesion in endocardium➡️deposition of fibrin over injured endocardium➡️endothelial overgrown➡️papillary outgrowths➡️hyalinize➡️fibrosed papillary outgrowths

8/ WHY DO WE CARE?!?
Lambl's Excrescences can separate form the valve surface ➡️ thromboembolize ➡️CVAs or acute coronary syndrome

Thus, keep LEs in your ddx for cryptogenic stroke & consider TEE in these cases.

9/ TREATMENT:
😀Asymptomatic ➡️Monitor on serial TEE, no need for anticoag

😕Symptomatic (TIA, CVA)➡️antiplatelet therapy ➡️Coumadin + ASA if recurrent episodes OR Surgery

There is controversy about which antiplatelet or AC agents to use and when. See this handy algorithm:

10/ Now, a post-tweetorial survey:

Which of the following are patients with Lambl's Excrescence at risk for:

11/ Curious to learn more?
This review article from earlier this year was really helpful in giving me a brief overview of Lambl's Excrescences.

Lambl’s Excrescences: Current Diagnosis and Management ncbi.nlm.nih.gov/pmc/articles/P…