From the Guidelines
Lambl's excrescences on the aortic valve should be managed based on stroke risk stratification, with antiplatelet therapy being the first-line treatment for patients who have experienced a cryptogenic stroke and no other identifiable stroke source. For patients with these filiform projections, the management strategy should prioritize the reduction of stroke risk while minimizing the risk of bleeding. According to the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1, antiplatelet therapy, such as aspirin 81-325 mg daily, is generally recommended as first-line treatment.
In cases of recurrent stroke despite antiplatelet therapy, anticoagulation with warfarin (target INR 2-3) or a direct oral anticoagulant like apixaban (5 mg twice daily) may be considered, as suggested by the PARTNER 2 investigators who reported a lower incidence of stroke and death with VKA therapy after TAVI in intermediate– or higher–surgical risk patients 1. However, the potential benefit of anticoagulation therapy must be weighed against the risk of bleeding, and an individualized approach that takes the risk of bleeding into account is required 1.
Surgical intervention is typically reserved for patients with large, mobile excrescences who have experienced recurrent strokes despite medical therapy. Lambl's excrescences are thin, filamentous structures that develop at valve closure lines due to endothelial damage and subsequent fibrin deposition. While they are considered normal age-related findings in many adults, they may serve as a potential source of thromboembolism, particularly when they are multiple, elongated (>2 mm), or highly mobile. Regular clinical follow-up with periodic echocardiographic assessment is important, especially for patients with a history of stroke. Lifestyle modifications to reduce overall cardiovascular risk, including blood pressure control, smoking cessation, and management of hyperlipidemia, should be implemented alongside specific therapy for the valve lesions.
Key considerations in the management of Lambl's excrescences include:
- Stroke risk stratification to guide treatment decisions
- Antiplatelet therapy as first-line treatment for patients with cryptogenic stroke
- Anticoagulation therapy for patients with recurrent stroke despite antiplatelet therapy
- Individualized approach to balance the benefits and risks of anticoagulation therapy
- Surgical intervention for patients with large, mobile excrescences and recurrent strokes despite medical therapy
- Regular clinical follow-up and lifestyle modifications to reduce overall cardiovascular risk.
From the Research
Lambl's Excrescence and Aortic Valve
- Lambl's excrescences (LEs) are filiform strands that form on heart valves, including the aortic valve, and are associated with an increased risk of stroke due to embolization 2, 3.
- LEs originate as small thrombi on endocardial surfaces and have the potential to embolize to distant organs, including the brain, leading to stroke or transient ischemic attack 3.
Stroke Risk and Management
- Patients with LEs on the aortic valve are at increased risk of stroke, and the management of incidentally discovered LEs in patients without an adverse cardioembolic event is less clear 2.
- Asymptomatic patients who are found to have evidence of LEs should be monitored closely, and if there is evidence of one cerebrovascular accident in a patient with LEs, anticoagulation is advised 3, 4.
- Surgical excision of LEs is recommended for patients who have experienced two or more cerebrovascular accidents or combined other heart disease and need open heart surgery 3, 4.
Diagnostic and Treatment Approaches
- Transesophageal echocardiography (TEE) is the main diagnostic means for LEs and should be included in the diagnostic assessment of all patients who have experienced strokes 3, 4.
- Anticoagulation therapy, such as aspirin or warfarin, may be used to prevent stroke in patients with LEs, although the optimal antithrombotic therapy is still debated 5, 6.
- Surgical treatment to remove LEs can be successfully performed, and follow-up studies have shown no new cerebrovascular accidents in patients who underwent surgical excision of LEs 2, 4.