What is the management approach for a 65-year-old woman with recurrent stroke and a 5 mm lambl (valvular) excrescence on the aortic valve?

From the Guidelines

For a 65-year-old woman with recurrent stroke and a 5 mm Lambl's excrescence on the aortic valve, I recommend anticoagulation therapy with warfarin (target INR 2.0-3.0) or a direct oral anticoagulant (DOAC) such as apixaban 5 mg twice daily. This treatment should be continued long-term given the recurrent nature of her strokes and the identified cardiac source. Lambl's excrescences are filiform fronds on heart valves that, when larger (as in this case at 5 mm), can serve as a nidus for thrombus formation and subsequent embolization. While antiplatelet therapy alone (such as aspirin 81-325 mg daily) might be considered for smaller excrescences, the combination of recurrent stroke and a relatively large excrescence warrants more aggressive anticoagulation, as suggested by the American Heart Association guidelines 1. Some key points to consider in the management of this patient include:

• The size of the Lambl's excrescence (5 mm) is significant and increases the risk of thromboembolic events, thus necessitating anticoagulation therapy.
• The patient's history of recurrent stroke indicates a high risk of future events, and anticoagulation is recommended to reduce this risk, as stated in the guidelines 1.
• Regular cardiac monitoring with echocardiography every 6-12 months is also recommended to assess for changes in the excrescence size or morphology.
• The patient should be evaluated by both neurology and cardiology for comprehensive management, as other stroke risk factors should be addressed concurrently, including hypertension, diabetes, hyperlipidemia, and lifestyle modifications.
• The guidelines from the American College of Cardiology/American Heart Association Task Force on Practice Guidelines also support the use of anticoagulation therapy in patients with valvular heart disease and a history of stroke or transient ischemic attack 1. However, the most recent and highest quality study, which is the 2021 guideline for the prevention of stroke in patients with stroke and transient ischemic attack, recommends anticoagulation with warfarin or a DOAC for patients with valvular disease and a history of stroke or TIA 1. Therefore, anticoagulation therapy with warfarin or a DOAC is the recommended treatment for this patient, given the recurrent nature of her strokes and the identified cardiac source.

From the FDA Drug Label

For patients with AF and mitral stenosis, anticoagulation with oral warfarin is recommended (7th ACCP) For patients with AF and prosthetic heart valves, anticoagulation with oral warfarin should be used; the target INR may be increased and aspirin added depending on valve type and position, and on patient factors. A moderate dose regimen (INR 2.0 to 3.0) is recommended for patients with valvular disease associated with atrial fibrillation, patients with mitral stenosis, and patients with recurrent systemic embolism of unknown etiology.

The patient has a history of recurrent stroke and lambl excrescence on the aortic valve. Although the label does not directly address lambl excrescence, it does provide guidance on anticoagulation therapy for patients with valvular heart disease and atrial fibrillation.

• The recommended INR target for these patients is 2.0-3.0.
• Warfarin therapy is recommended for patients at high risk of stroke, including those with a history of ischemic stroke.
• The patient's age (65 years) and history of recurrent stroke put her at high risk of stroke, so anticoagulation therapy with warfarin is likely warranted 2.

From the Research

Diagnosis and Management of Lambl's Excrescences

• Lambl's excrescences (LE) are threadlike fronds that occur along valve closure lines, resulting in thrombus formation and potentially leading to cerebral embolism and coronary artery obstruction 3, 4, 5.
• The gold standard for diagnosis of LE is transesophageal echocardiography (TEE) 3, 4, 5.
• In patients with recurrent ischemic events, anticoagulation should be offered, along with discussion about surgical excision 3.
• Asymptomatic LEs are closely monitored, while symptomatic lesions with history of thromboembolism are managed with antiplatelet drugs or are anticoagulated 4.

Treatment Options for Recurrent Stroke

• Patients with the first stroke episode can be treated conservatively with antiplatelet therapy 3.
• The use of Aspirin is suggested for patients with ≥1 embolic event attributed to LE while not on antiplatelets or anticoagulants, as it is the most used and recommended treatment option and is effective in preventing recurrent thromboembolic events 5.
• Surgery is indicated in case of recurrent thromboembolic episodes occurring while on medications 4.

Considerations for the Given Case

• A 65-year-old woman with recurrent stroke and a 5 mm Lambl's excrescence on the aortic valve may require anticoagulation and discussion about surgical excision, considering her recurrent ischemic events 3.
• The patient's treatment plan should be individualized, taking into account her specific condition and medical history 6.
• A stepwise approach, using clinical, imaging, and laboratory clues to direct further invasive testing, is required for proper diagnosis and management in such cases 6.