Background: Strokes or cerebrovascular accidents carry significant morbidity and mortality weight in the United States and is the fifth leading cause of death (1). Cardiac sources for emboli account for 14-30% of all ischemic strokes (2). Lambl’s excrescences (LE) are rare outgrowths on the coaptations sites of the heart valves that appear to be thin, filiform, mobile strands on echocardiogram (3).

Case presentation: A 75 year-old male with a known past medical history of coronary artery disease status-post coronary artery bypass surgery x3 in 2005, who presented to the hospital in September 2019, complaining of lightheadedness and vertigo. A CT scan of the head was done as part of stroke protocol, and showed age-related parenchymal volume loss, small vessel disease, small right posterior parietal lobe cortical infarct. MRI of the brain the next day was done showing a small foci of subacute infarct in the right parietal lobe and another infarct in the cerebellar vermis, consistent with embolic events. A Transthoracic echocardiogram (TTE) revealed a left ventricular ejection fraction (LVEF) 40-50%, no LV thrombus, and no evidence of a patent foramen ovale (PFO). .A transesophageal echocardiogram (TEE) demonstrated no left atrial (LA) thrombus, a normal LA appendage, but LE was seen on the non-coronary cusp of the aortic valve. An implantable loop recorder (ILR) was implanted before discharge, that later did not show any arrhythmias on interrogation. He was started on Apixaban and Aspirin in the hospital and was discharged with a prescription and follow up as outpatient.

Final Diagnosis: Lambl’s excrescences are outgrowths found most commonly on mitral and/or aortic valves, capable of forming an embolus, which can then detach and cause ischemic events distally, but also a thrombus can develop on LE which can then send shower emboli (4). Multiple case reports have been described in the literature without any consensus on best management and treatment approach reached yet (5). So far, the current recommendations are to perform a TEE for diagnosis. Most authors agree on starting a trial of either dual anti-platelet therapy or anticoagulation, before moving forward to more invasive therapy options, including surgical valve replacement (6). However, there is a general consensus to manage the patients on a case-by-case basis.

Conclusion: In conclusion, a review of the most recent literature and recommendations on workup and management of Lambl’s excrescences shows that there is no consensus on how to proceed. It should always be tailored to the patient and studied on a case-by-case basis, with a multi-specialty team approach including internal medicine, cardiovascular medicine as well as cardiothoracic surgeons. Although a rare condition, it should be considered in patients presenting with thromboembolic events, since it has the potential to have catastrophic outcomes.

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