Rambles about Lambls: Lambl Excrescences of the Aortic Valve

Introduction: This case identifies a 56-year-old female with hypertension and cryptogenic strokes possibly caused by lambl excrescences (LEs). LEs are rare, degenerative fibers that develop at valvular coaptation sites. They're thought to arise from blood-flow jets causing shearing forces on the valves. Only 5.5% of all patients referred for TEE are found to have LEs, but this increases to 40% of those undergoing cryptogenic stroke workup. Currently, LEs are considered incidental findings on imaging though they may actually be the cause of cryptogenic strokes.

Case Study: The patient presented to the ED after waking with a sudden, significant decrease in strength of her right upper and lower extremities. Upon physical exam, strength in her right lower extremity was ⅗ and ⅘ in her right upper extremity. Asymmetry was noted in her right nasolabial fold with significant dysmetria on finger-to-nose and heel-to-shin tests.
She was admitted with continuous telemetry monitoring and serial neurology exams. MRI and TEE were ordered, neurology and cardiology consulted. This workup would assess the extent of the brain injury and monitor for atrial fibrillation, atrial septal defects, and various emboli as possible causes.
The neurologist restarted aspirin and increased her statin dose. The cardiologist acknowledged that she had a cardiac monitor four months prior showing no evidence of atrial fibrillation. The MRI showed acute lacunar infarcts within the bilateral thalami and TEE showed small filiform structures on the aortic valve, suggestive of LEs. Of note, this patient had received at least four outpatient TTEs reporting poor visualization of the aortic valve.

Discussion: While there is no clear causal relationship between LEs and CVAs, the risk of fragmentation and embolization of these strands warrants consideration since anticoagulation would not be beneficial; valvular debridement or replacement would be required. The literature describes a 61-year-old female with recurrent strokes and LEs. As a diagnosis of exclusion, she underwent successful debridement of the excrescences. To the authors’ knowledge, she has not had additional CVAs.
This case represents the osteopathic tenet that structure and function are reciprocally interrelated. The heart and its inner structures were not designed to function in hypertensive conditions. When hypertension goes untreated, there can be unusual wear and tear on the valves within the heart, leading to LEs and possibly CVAs.
When discussing LEs, few have heard of them and even fewer know what they may be capable of. For this reason, I believe sharing this case is crucial for continued learning.