Clinical impact of valvular strands or Lambl's excrescences in the real-world practice

Abstract

Abstract Background Due to recent advancements in high-resolution echo systems, valvular strands or Lambl’s excrescences are frequently observed in daily clinical practice. However, it can be challenging to differentiate these valvular structures as fibroelastomas or infective endocarditis. Although those redundant cardiac tissues are reported to cause embolic events, the incidence or outcomes of valvular strands and Lambl’s excrescences have not been well investigated. Purpose To investigate the clinical impact of valvular strands or Lambl’s excrescences (VS/LEs) on clinical outcomes. Methods We searched our hospital’s institutional echocardiography database for transthoracic echocardiography (TTE), or transesophageal echocardiography (TEE) reports with VS/LEs between 2018 and 2022. Patients diagnosed with infectious endocarditis or overt papillary fibroelastoma were excluded. Clinical outcomes of all-cause death, ischemic stroke, systemic embolism, or surgical resection were evaluated from the electronic medical chart. We analyzed the cumulative incidences of each clinical outcome for the entire cohort, and we compared cases assessed by TEE (With TEE) and cases confirmed by TTE only (TTE only). Results From the 53799 TTE and 3186 TEE tests, we found 340 reports from 174 cases with VS/LEs (With TEE, 67 cases, and TTE only, 107 cases). Only one stroke case was suspected of aortic valve strand origin for stroke at the index TEE or TTE. Surgical resection was performed in two cases (one each in With TEE and TTE only groups) within 30 days from the first detection of the VS/LEs. The median follow-up period was 355 days. We observed all-cause death in 8 cases (6.1%: With TEE, 1 case [1.6%] and TTE only, 7 cases [8.6%], P=0.09). Ischemic stroke occurred in 6 cases (5.0%: With TEE, 3 cases [6.5%], TTE only, 3 cases [4.1%], P=0.27). None of the deaths were associated with embolic events. We performed landmark analysis at 30 days for surgical resection, and five cases underwent surgical treatment at one year (With TEE, 5 cases, and TTE only, no case). All surgical resections for the VS/LEs were performed concurrently with other cardiac operations. Conclusions In this study, we observed that most VS/LEs were managed non-invasively and rarely associated with embolic events, especially TTE-only detected VS/LEs.