Giant Aortic Lambl's Excrescence

BACKGROUND: Lambl's excrescences (LEs) are thin, filamentous valvular strands that are usually small and asymptomatic, however when they are large and mobile, they can cause embolic or obstructive events. CASE SUMMARY: A 59-year-old man presented with recurrent angina-like chest pain. Coronary angiography showed an intermediate lesion in the left anterior descending artery without hemodynamic relevance. Echocardiography revealed a highly mobile, 20- to 30-mm filamentous structure attached to the left coronary cusp, intermittently prolapsing toward the left coronary ostium and causing moderate aortic regurgitation. Surgical excision and aortic valve replacement were performed through a ministernotomy. Symptoms resolved, and histopathology confirmed a giant LE. DISCUSSION: Giant or hypermobile LEs can dynamically obstruct coronary ostia, mimicking atherosclerotic angina, even without significant coronary vascular disease. Surgical treatment is recommended when lesions are large, symptomatic, or associated with an increased risk of embolism. TAKE-HOME MESSAGE: Large LEs may cause coronary obstruction; multimodality imaging is essential, timely surgical removal provides relief and prevents ischemic or embolic complications.