Breathless and Bewildered With Respiratory Failure and Lambl's Excrescence

Document Type

Conference Proceeding

Publication Date

10-2025

Publication Title

Chest

Abstract

INTRODUCTION: Lambl's excrescences (LE) are thin, filamentous, valvular structures that arise from the closure lines of cardiac valves, particularly the aortic valve. These structures are often considered incidental findings with uncertain clinical significance. However, emerging evidence suggests their potential role in thromboembolic events. We present a case of an elderly patient in whom LE was identified incidentally during an evaluation for acute encephalopathy, raising important considerations regarding its clinical implications and the necessity of systematic assessment in critical care settings. CASE PRESENTATION: A 75-year-old woman with a history of atrial fibrillation on warfarin, morbid obesity (BMI 53.82 kg/ m2 ), and oxygen-dependent chronic obstructive pulmonary disease (COPD) on 2L/min supplemental oxygen was brought to the hospital by emergency medical services after being found unresponsive. She was intubated emergently for airway protection. Initial venous blood gas revealed acute respiratory acidosis (pH 7.31, pCO2 100 mmHg). Laboratory investigations showed a normal anion gap, normal brain natriuretic peptide, negative troponin, and an unremarkable urine toxicology screen. Computed tomography pulmonary angiography ruled out pulmonary embolism but showed atelectasis/consolidation in the left lower and right upper lobes. Computed tomography of the head and cervical spine showed no acute pathology. Blood cultures did not grow any organisms. Further, her Bronchoscopy revealed thick secretions and excessive dynamic airway collapse with respiratory cultures demonstrating normal flora. Her encephalopathy was attributed to hypercapnic respiratory failure. During hospitalization, transthoracic echocardiography revealed a left ventricular ejection fraction of 65% with grade 2 diastolic dysfunction. Notably, a mobile, filiform structure on the aortic valve, consistent with LE, was identified. No significant aortic stenosis, aortic regurgitation, or intracardiac thrombi were noted. Given her clinical presentation, stroke was ruled out, and she was successfully extubated with improvement in mental status. DISCUSSION: Lambl's excrescences are often considered benign but can be associated with thromboembolic complications, including ischemic strokes. LEs may be found in up to 39% of elderly patients undergoing echocardiography for suspected cardiogenic embolic stroke. In our patient, the identification of a mobile structure on the aortic valve during echocardiography necessitated careful consideration of the differential diagnoses. Infective endocarditis was ruled out due to the absence of clinical signs such as fever or positive blood cultures. Additionally, the normal brain natriuretic peptide (BNP) levels and negative troponin tests further supported the absence of significant cardiac dysfunction or acute coronary syndrome. The mobile nature of the excrescence, combined with the patient's history of atrial fibrillation, raises the possibility of it being a source of emboli that could contribute to her acute encephalopathy. In our case, the patient was successfully extubated and showed improvement in mental status, indicating that her acute respiratory failure was primarily due to hypercapnia rather than a direct consequence of the Lambl's excrescence. CONCLUSIONS: In conclusion, this case illustrates the importance of recognizing Lambl's excrescences as a potential source of embolic complications in patients with atrial fibrillation. While the presence of LEs may be incidental, their association with thromboembolic events necessitates careful evaluation and consideration of management strategies.

Volume

168

Issue

4S

First Page

1117A

Comments

American College of Chest Physicians CHEST Annual Meeting, October 19-22, 2025, Chicago, IL

Last Page

1118A

DOI

10.1016/j.chest.2025.07.651

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