The serpentine mitral valve and cerebral embolism

Abstract

Valvular strands, well-delineated filiform masses, attached to cardiac valve edges are associated with cerebral embolism and stroke. Strokes, caused by emboli from valvular strands, tend to occur among younger persons.In this case report a valvular strand, giving a peculiar serpentine appearance to the mitral valve is described. This mitral valvular strand was the only explanation for an episode of cerebral embolism, presenting with a transient right sided hemiparesis.It is proposed that a randomized study involving combined treatment with aspirin and clopidogrel is warranted in young patients with valvular strands, presenting with a first episode of cerebral embolism.

Lambl’s excrescences and a review of therapeutic strategies

“…Previous case reports have suggested a variety of treatment modalities, including anticoagulation, antiplatelet therapy, surgical excision, and conservative management. [15,24,27,[34][35][36][37] Medical management within itself varied greatly, ranging from aspirin alone, dual antiplatelet therapy, novel oral anticoagulants, to full anticoagulation therapy with warfarin. [18,24,27,34,36] Roldan et al performed a study that suggests LEx may not be a source of cardioembolic strokes, and it may be reasonable to not treat them at all.…”

“…[15,24,27,[34][35][36][37] Medical management within itself varied greatly, ranging from aspirin alone, dual antiplatelet therapy, novel oral anticoagulants, to full anticoagulation therapy with warfarin. [18,24,27,34,36] Roldan et al performed a study that suggests LEx may not be a source of cardioembolic strokes, and it may be reasonable to not treat them at all. [4] While there is no consensus on a preferred treatment modality, our literature review revealed that in five of the six studies where the patient presented with a TIA, the patients were treated with a combination of antiplatelet therapy with different agents, and only one patient was treated with surgical excision.…”

“…[4] While there is no consensus on a preferred treatment modality, our literature review revealed that in five of the six studies where the patient presented with a TIA, the patients were treated with a combination of antiplatelet therapy with different agents, and only one patient was treated with surgical excision. [13,16,[34][35][36]39] In a patient whose medical compliance may be an issue, surgical excision may be a better option for a patient with TIA/CVA symptoms secondary to LEx given the bleeding risk on antiplatelet/anticoagulation therapy. Those patients also experienced positive outcomes, similar to those managed conservatively.…”

“…Manolakis [33] 47 y/o F Aortic valve CVA Warfarin (not adherent) Experienced another stroke, secondary to cocaine use Surgical excision Jo [34] Villella [35] 63 y/o M Mitral valve TIA Antiplatelet therapy Still having symptoms 2 months later, but less frequent Ker [36] 32 y/o M Mitral valve TIA ASA 100 mg, clopidogrel 75 mg No neuro event after 3 years follow-up Fumero [37] 30 y/o M Mitral valve CVA Surgical excision No neuro event after 1 year follow-up Nighoghossian [38] 31 y/o M Mitral valves Recurrent CVA Acenocoumarol; Surgical excision Not reported Bruinsma [39] 34 y/o M Mitral valve TIA Surgical excision Not reported…”

Lambl’s excrescences and a review of therapeutic strategies

“…Previous case reports have suggested a variety of treatment modalities, including anticoagulation, antiplatelet therapy, surgical excision, and conservative management. [15,24,27,[34][35][36][37] Medical management within itself varied greatly, ranging from aspirin alone, dual antiplatelet therapy, novel oral anticoagulants, to full anticoagulation therapy with warfarin. [18,24,27,34,36] Roldan et al performed a study that suggests LEx may not be a source of cardioembolic strokes, and it may be reasonable to not treat them at all.…”

“…[15,24,27,[34][35][36][37] Medical management within itself varied greatly, ranging from aspirin alone, dual antiplatelet therapy, novel oral anticoagulants, to full anticoagulation therapy with warfarin. [18,24,27,34,36] Roldan et al performed a study that suggests LEx may not be a source of cardioembolic strokes, and it may be reasonable to not treat them at all. [4] While there is no consensus on a preferred treatment modality, our literature review revealed that in five of the six studies where the patient presented with a TIA, the patients were treated with a combination of antiplatelet therapy with different agents, and only one patient was treated with surgical excision.…”

“…[4] While there is no consensus on a preferred treatment modality, our literature review revealed that in five of the six studies where the patient presented with a TIA, the patients were treated with a combination of antiplatelet therapy with different agents, and only one patient was treated with surgical excision. [13,16,[34][35][36]39] In a patient whose medical compliance may be an issue, surgical excision may be a better option for a patient with TIA/CVA symptoms secondary to LEx given the bleeding risk on antiplatelet/anticoagulation therapy. Those patients also experienced positive outcomes, similar to those managed conservatively.…”

“…Manolakis [33] 47 y/o F Aortic valve CVA Warfarin (not adherent) Experienced another stroke, secondary to cocaine use Surgical excision Jo [34] Villella [35] 63 y/o M Mitral valve TIA Antiplatelet therapy Still having symptoms 2 months later, but less frequent Ker [36] 32 y/o M Mitral valve TIA ASA 100 mg, clopidogrel 75 mg No neuro event after 3 years follow-up Fumero [37] 30 y/o M Mitral valve CVA Surgical excision No neuro event after 1 year follow-up Nighoghossian [38] 31 y/o M Mitral valves Recurrent CVA Acenocoumarol; Surgical excision Not reported Bruinsma [39] 34 y/o M Mitral valve TIA Surgical excision Not reported…”

Lambl’s Excrescences: Current Diagnosis and Management

“…Patients who have LE and have experienced one episode of transient ischemic attack (TIA)/CVA should be treated conservatively with antiplatelet therapy. While some authors report the use of aspirin alone [17, 18], others have advocated dual antiplatelet therapy (DAPT) with the addition of clopidogrel [14, 19]. There is no general consensus in the literature about whether to use anticoagulation [5, 20] versus antiplatelet therapy in a patient with a single embolic episode with LE.…”

Lambl’s excrescences and a review of therapeutic strategies

“…Previous case reports have suggested a variety of treatment modalities, including anticoagulation, antiplatelet therapy, surgical excision, and conservative management. [15,24,27,[34][35][36][37] Medical management within itself varied greatly, ranging from aspirin alone, dual antiplatelet therapy, novel oral anticoagulants, to full anticoagulation therapy with warfarin. [18,24,27,34,36] Roldan et al performed a study that suggests LEx may not be a source of cardioembolic strokes, and it may be reasonable to not treat them at all.…”

“…[15,24,27,[34][35][36][37] Medical management within itself varied greatly, ranging from aspirin alone, dual antiplatelet therapy, novel oral anticoagulants, to full anticoagulation therapy with warfarin. [18,24,27,34,36] Roldan et al performed a study that suggests LEx may not be a source of cardioembolic strokes, and it may be reasonable to not treat them at all. [4] While there is no consensus on a preferred treatment modality, our literature review revealed that in five of the six studies where the patient presented with a TIA, the patients were treated with a combination of antiplatelet therapy with different agents, and only one patient was treated with surgical excision.…”

“…[4] While there is no consensus on a preferred treatment modality, our literature review revealed that in five of the six studies where the patient presented with a TIA, the patients were treated with a combination of antiplatelet therapy with different agents, and only one patient was treated with surgical excision. [13,16,[34][35][36]39] In a patient whose medical compliance may be an issue, surgical excision may be a better option for a patient with TIA/CVA symptoms secondary to LEx given the bleeding risk on antiplatelet/anticoagulation therapy. Those patients also experienced positive outcomes, similar to those managed conservatively.…”

“…Manolakis [33] 47 y/o F Aortic valve CVA Warfarin (not adherent) Experienced another stroke, secondary to cocaine use Surgical excision Jo [34] Villella [35] 63 y/o M Mitral valve TIA Antiplatelet therapy Still having symptoms 2 months later, but less frequent Ker [36] 32 y/o M Mitral valve TIA ASA 100 mg, clopidogrel 75 mg No neuro event after 3 years follow-up Fumero [37] 30 y/o M Mitral valve CVA Surgical excision No neuro event after 1 year follow-up Nighoghossian [38] 31 y/o M Mitral valves Recurrent CVA Acenocoumarol; Surgical excision Not reported Bruinsma [39] 34 y/o M Mitral valve TIA Surgical excision Not reported…”

Lambl’s Excrescences: Current Diagnosis and Management

“…Patients who have LE and have experienced one episode of transient ischemic attack (TIA)/CVA should be treated conservatively with antiplatelet therapy. While some authors report the use of aspirin alone [17, 18], others have advocated dual antiplatelet therapy (DAPT) with the addition of clopidogrel [14, 19]. There is no general consensus in the literature about whether to use anticoagulation [5, 20] versus antiplatelet therapy in a patient with a single embolic episode with LE.…”

Lambl’s excrescences and a review of therapeutic strategies

“…Previous case reports have suggested a variety of treatment modalities, including anticoagulation, antiplatelet therapy, surgical excision, and conservative management. [15,24,27,[34][35][36][37] Medical management within itself varied greatly, ranging from aspirin alone, dual antiplatelet therapy, novel oral anticoagulants, to full anticoagulation therapy with warfarin. [18,24,27,34,36] Roldan et al performed a study that suggests LEx may not be a source of cardioembolic strokes, and it may be reasonable to not treat them at all.…”

“…[15,24,27,[34][35][36][37] Medical management within itself varied greatly, ranging from aspirin alone, dual antiplatelet therapy, novel oral anticoagulants, to full anticoagulation therapy with warfarin. [18,24,27,34,36] Roldan et al performed a study that suggests LEx may not be a source of cardioembolic strokes, and it may be reasonable to not treat them at all. [4] While there is no consensus on a preferred treatment modality, our literature review revealed that in five of the six studies where the patient presented with a TIA, the patients were treated with a combination of antiplatelet therapy with different agents, and only one patient was treated with surgical excision.…”

“…[4] While there is no consensus on a preferred treatment modality, our literature review revealed that in five of the six studies where the patient presented with a TIA, the patients were treated with a combination of antiplatelet therapy with different agents, and only one patient was treated with surgical excision. [13,16,[34][35][36]39] In a patient whose medical compliance may be an issue, surgical excision may be a better option for a patient with TIA/CVA symptoms secondary to LEx given the bleeding risk on antiplatelet/anticoagulation therapy. Those patients also experienced positive outcomes, similar to those managed conservatively.…”

“…Manolakis [33] 47 y/o F Aortic valve CVA Warfarin (not adherent) Experienced another stroke, secondary to cocaine use Surgical excision Jo [34] Villella [35] 63 y/o M Mitral valve TIA Antiplatelet therapy Still having symptoms 2 months later, but less frequent Ker [36] 32 y/o M Mitral valve TIA ASA 100 mg, clopidogrel 75 mg No neuro event after 3 years follow-up Fumero [37] 30 y/o M Mitral valve CVA Surgical excision No neuro event after 1 year follow-up Nighoghossian [38] 31 y/o M Mitral valves Recurrent CVA Acenocoumarol; Surgical excision Not reported Bruinsma [39] 34 y/o M Mitral valve TIA Surgical excision Not reported…”

Lambl’s Excrescences: Current Diagnosis and Management

“…Patients who have LE and have experienced one episode of transient ischemic attack (TIA)/CVA should be treated conservatively with antiplatelet therapy. While some authors report the use of aspirin alone [17, 18], others have advocated dual antiplatelet therapy (DAPT) with the addition of clopidogrel [14, 19]. There is no general consensus in the literature about whether to use anticoagulation [5, 20] versus antiplatelet therapy in a patient with a single embolic episode with LE.…”