Cas du 06/04/2015: Aortic Valve String

Presentation: A patient scheduled for a CABG has the following echo loop.

#1: What is the diagnosis?
#2: What is the recommended therapy?
























Explanation: The diagnosis is Lambl's Excressence (LE). The differential diagnosis would be an artifact, thrombus, redundant AV cusp, aortic dissection intimal flap, and a papillary fibroeslastoma (PFE). Artifacts can be ruled out by being absent in other imaging planes. A thrombus is usually a thick globular structure whereas this is a thin, filamentous, flapping structure. If the cusp edges can be visualized, then redundant cusp tissue is not th e etiology. PFE are usually small, pedunculated, mobile masses. PFE are jelly-like whereas LE are fibrous tissue.

LE can be associated with CVA/TIAs but some studies dispute the association. The recommendation for an asymptomatic patient is to not remove the LE while antithrombotic therapy may be reasonable. For patients who have had a CVA/TIA where LE is the only abnormality - the current recommendation is to not  remove the LE, although some have advocated LE resection in those settings.