RESEARCH FROM OR IN COLLABORATION WITH THE UNIVERSITY OF ALABAMA AT BIRMINGHAM Incremental Value of Three-Dimensional Transesophageal Echocardiography over Two-Dimensional Transesophageal Echocardiography in the Assessment of Lambl’s Excrescences and Nodules of Arantius on the Aortic Valve Bhavin Dumaswala, M.B.B.S.,* 1 Komal Dumaswala, M.B.B.S.,* 1 Ming Chon Hsiung, M.D.,† 1 Luis David Meggo Quiroz, M.D.,‡ Aylin Sungur, M.D.,* Maximilliano German Amado Escanuela, M.D.,* Kruti Mehta, M.B.B.S.,* Tugba Kemaloglu Oz, M.D.,* Kunal Bhagatwala, M.B.B.S.,* Nidhi M. Karia, M.B.B.S.,* and Navin C. Nanda, M.D.* *Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, Alabama; †Heart Center, Division of Cardiology, Cheng Hsin General Hospital, Taipei, Taiwan, Republic of China; and ‡Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama In this retrospective study, we identified 7 cases where Lambl’s excrescences were identified by two- dimensional transesophageal echocardiography (2DTEE) and also had live/real time three-dimensional transesophageal echocardiography (3DTEE) studies available for comparison. We subsequently assessed them for the presence of Lambl’s excrescences (LE) and nodules of Arantius (NA) on the aortic valve. After their identification, we qualitatively and quantitatively organized our findings by number, cusp location, measurements, and orientation if applicable. A greater number of LE was found by 3DTEE than 2DTEE (19 vs. 11, respectively). In all 3DTEE studies, their cusp attachment site, their x-, y-, and z-axis measurements, and orientation were clearly visualized and described. Only 3DTEE studies provided con- fident visualization of the cusp attachment sites. Similarly, a greater number of NA was found by 3DTEE than 2DTEE (21 vs. 5, respectively). The triad of NA was visualized in all 3DTEE studies and each was described using its x-, y-, and z- axis measurements. Only three 2DTEE studies provided reliable identifi- cation of the NA. In conclusion, we present further evidence of the incremental value of 3DTEE over 2DTEE in the qualitative and quantitative assessment of cardiac structures including LE and NA on the aortic valve. (Echocardiography 2013;30:967‐975) Key words: aortic valve, Lambl’s excrescences, nodules of Arantius, echocardiography, three- dimensional echocardiography, three-dimensional transesophageal echocardiography, two-dimensional transesophageal echocardiography A Lambl’s excrescence (LE) is the histological term that refers to the echocardiographic finding of a valvular strand. Lambl of Prague first described it in 1856 as a small, filiform projection of fibrous tissue covered by a single layer of endothelial cells on the cusps of the aortic valve. All early reports were based on postmortem examinations, and with the development of echocardiography, these structures now have been found on the native aortic, mitral, pulmonary and tricuspid valves, and prosthetic aortic and mitral valves. They are visualized on an echocardiogram as highly mobile, fine, thread- like excrescences, which are more common in the elderly as compared with young adults. Unlike fibroelastomas, they are neither peduncu- lated nor multilayered with endothelial cells. It is postulated that they originate at sites of minor endothelial damage from wear and tear, such as valvular closure lines, and in high pressure condi- tions; thus their predominance in the left side of the heart. 1 They can grow to large sizes from continuous layering of fibrin and can cause obstruction of the coronary arteries 2 or valvular 1 These authors contributed equally to the manuscript. Address for correspondence and reprint requests: Navin C. Nanda, M.D., University of Alabama at Birmingham, Echo Lab SW/S102, 619 19th Street South, Birmingham, AL 35249. Fax: 205-934-6747; E-mail: nanda@uab.edu 967 © 2013, Wiley Periodicals, Inc. DOI: 10.1111/echo.12310 Echocardiography