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Pathologic Examination of Lambl’s Excrescence

2013; Elsevier BV; Volume: 28; Issue: 1 Linguagem: Inglês

10.1053/j.jvca.2013.06.019

1532-8422

Junko Nakahira, Toshiyuki Sawai, Toshiaki Minami,

Atrial Fibrillation Management and Outcomes

We read with interest the article titled “Endovascular transcatheter aortic valve implantation: An evolving standard” published by Sfeir PM et al.1Sfeir P.M. Abchee A.B. Ghazzal Z. et al.Endovascular transcatheter aortic valve implantation: An envolving standard.J Cardiothorac Vasc Anesth. 2013; 27: 765-778Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar In view of the greying of the population and the higher age of patients, severe aortic stenosis patients who undergo transcatheter aortic valve implantation are more likely to have Lambl’s excrescences than 10 years ago. Lambl’s excrescences are small, mobile valvular strands made up of connective tissue. They are thin ( 10 mm) filiform projections from heart valves that show undulating independent motion.2Ionescu A.A. Newman G.R. Butchart E.G. et al.Morphologic analysis of a strand recovered from a prosthetic mitral valve: No evidence of fibrin.J Am Soc Echocardiogr. 1999; 12: 766-768Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar They are more commonly seen on the mitral valve than on the aortic valve, typically near the closure line of the mitral valve. Although it was first reported that they were composed of fibrin, morphologic analysis revealed the presence of collagen.3Nighoghossian N. Derex L. Perinetti M. et al.Course of valvular strands in patients with stroke: Cooperative study with transesophageal echocardiography.Am Heart J. 1998; 136: 1065-1069Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar Several previous case reports have shown no common morphologic and histologic structures for Lambl’s excrescences.4Dangas G. Dailey-Sterling F.G. Sharma S.K. et al.Non-Q-wave infarction and ostial left coronary obstruction due to giant Lambl’s excrescences of the aortic valve.Circulation. 1999; 99: 1919-1921Crossref PubMed Scopus (6) Google Scholar, 5Aziz F. Baciewicz Jr, F.A. Lambl’s excrescences: Review and recommendations.Tex Heart Inst J. 2007; 34: 366-368PubMed Google Scholar Here, we wish to share our experience of a patient with Lambl’s excrescence. We have included histologic images of the excrescence. While providing anesthesia for a patient undergoing mitral valve replacement surgery, we performed transesophageal echocardiography and found the Lambl’s excrescence on the aortic valve in the form of a 12-mm fibrous tissue (Fig 1). We presumed it was a flapping piece torn from the commissure between the right and left coronary cusps along the edge of the left coronary cusp. Pathologic examination of the tissue with hematoxylin eosin staining revealed that the structure consisted of connective tissue covered by a single layer of endothelial cells (Fig 2). Examination with Elastica Van Gieson’s stain showed that it had a collagenous structure with elastic fibers inside and was surrounded by loose connective tissue (Fig 3). Hence, it was diagnosed as a typical Lambl’s excrescence. Since these excrescences are similar in composition to cardiac valves, the strand was assumed to have come off the surface of the valve to which the strand was attached due to the flow of blood.Fig 2Longitudinal section of the resected strand stained with hematoxylin and eosin. The structure consisted of connective tissue covered by a single layer of endothelial cells.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3Longitudinal section of the resected strand stained with Elastica Van Gieson’s stain. The resected structure consisted of collagenous fibers with elastic fibers inside, these being surrounded by loose connective tissue.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Endovascular Transcatheter Aortic Valve Implantation: An Evolving StandardJournal of Cardiothoracic and Vascular AnesthesiaVol. 27Issue 4PreviewABNORMALITIES OF THE aortic valve morphology and function represent the most common cardiac valve lesion, with relevant implications for medical and surgical treatment. Aortic valve sclerosis affects about one fourth of adults over 65 years of age, whereas severe aortic stenosis (AS) is present in 2% to 9% of the same population.1 AS is suspected to be the result of chronic inflammation secondary to risk factors similar to the ones associated with atherosclerosis.2,3 The number of aortic valve procedures performed over the last 10 years increased if aortic valve replacement is considered alone or combined with myocardial revascularization; mitral valve surgery seemed to be constant in the same period. Full-Text PDF