Mitral Valve Prolapse

Mitral Valve Prolapse

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Mitral valve prolapse (MVP) is the most common valvular abnormality, affecting approximately 2-3% of the population in the United States. MVP usually has a benign course, but it occasionally leads to serious complications, including clinically significant mitral regurgitation (MR), infective endocarditis, sudden cardiac death, and cerebrovascular ischemic events.

Most patients with MVP are asymptomatic. Symptoms are related to one of the following:

Progression of MR

An associated complication (ie, stroke, endocarditis, or arrhythmia)

Autonomic dysfunction (The association between autonomic dysfunction and MVP remains unconfirmed.)

Symptoms related to progression of MR include the following:

Fatigue

Dyspnea

Exercise intolerance

Orthopnea

Paroxysmal nocturnal dyspnea (PND)

Progressive signs of chronic heart failure (CHF)

Palpitations (from associated arrhythmias)

Symptoms related to autonomic dysfunction are usually associated with genetically inherited MVP and may include the following:

Anxiety

Panic attacks

Arrhythmias

Exercise intolerance

Palpitations

Atypical chest pain

Fatigue

Orthostasis

Syncope or presyncope

Neuropsychiatric symptoms

Common general physical features associated with MVP include the following:

Asthenic body habitus

Low body weight or BMI

Straight-back syndrome

Scoliosis or kyphosis

Pectus excavatum

Hypermobility of the joints

Arm span greater than height (which may be indicative of Marfan syndrome)

The classic auscultatory finding is a mid-to-late systolic click. It may or may not be followed by a high-pitched, mid-to-late systolic murmur at the cardiac apex. These can vary with the following maneuvers:

A Valsalva maneuver or having the patient stand result in an earlier click, closer to the first heart sound, and a prolonged murmur. It may even bring out a murmur when none is heard at rest.

The supine position, especially with the legs raised, results in a click later in systole and a shortened murmur

See Clinical Presentation for more detail.

Findings on echocardiography are as follows:

Classic MVP: The parasternal long-axis view shows greater than 2-mm superior displacement of the mitral leaflets into the left atrium during systole, with a leaflet thickness of at least 5 mm

Nonclassic MVP: Displacement is more than 2 mm, with a maximal leaflet thickness of less than 5 mm

Other echocardiographic findings that should be considered as criteria are leaflet thickening, redundancy, annular dilatation, and chordal elongation

See Workup for more detail.

For purposes of treatment, patients with MVP can be divided into the following categories:

Asymptomatic patients with minimal disease

Patients with symptoms of autonomic dysfunction

Patients with evidence of progression to severe MR

Patients with neurologic findings

Patients with a mid-systolic click and late-systolic MR murmur

Treatment measures for asymptomatic patients with minimal disease

Reassurance of the benign prognosis

Initial echocardiography for risk stratification; if no clinically significant mitral regurgitation and thin leaflets are observed, clinical examinations and echocardiographic studies can be scheduled every 3-5 years

Encouragement to pursue a normal, unrestricted lifestyle with vigorous exercise

Treatment measures for patients with symptoms of autonomic dysfunction

Different measures that may be aimed at orthostatic intolerance

Abstinence from stimulants such as caffeine, alcohol, and cigarettes

An ambulatory 24-hour Holter monitor may be useful to detect supraventricular and/or ventricular arrhythmias

Treatment measures for patients with evidence of or progression to severe MR

Close follow-up and  consideration for surgical referral weighing the reparability of the lesion and signs of ventricular dysfunction (eg, enlarged ventricular dimensions, presence of atrial fibrillation, or pulmonary hypertension).

Treadmill stress test for exercise tolerance if the physician is unsure the patient is asymptomatic

Treatment measures for patients with central neurologic findings

Atrial fibrillation should be actively sought (see Cryptogenic Stroke evaluation). If it is not found, antiplatelet therapy with clopidogrel or aspirin may be considered for risk factor modification.

Cessation of smoking and oral contraceptive use

Appropriate anticoagulant treatment should be considered for patients with atrial fibrillation and a history of stroke/transient ischemic attack (TIA) according to general atrial fibrillation guidelines

See Treatment and Medication for more detail.

Mitral valve prolapse (MVP) is the most common valvular abnormality, affecting approximately 2-3% of the population in the United States. [1, 2] It is generally defined as the systolic displacement of one or more abnormally thickened, redundant mitral leaflet(s) into the left atrium during systole. [3]  It may be familial or sporadic with the majority of data favoring an autosomal dominant pattern of inheritance in a large proportion of individuals with MVP. [4, 5]  It is also the most common cause of isolated mitral regurgitation (MR) requiring surgical repair. [6]

MVP usually results in a benign course. However, it occasionally leads to serious complications, including clinically significant MR, infective endocarditis, sudden cardiac death, and cerebrovascular ischemic events.

Mitral valve prolapse (MVP) is characterized primarily by myxomatous degeneration of the mitral valve leaflets. In younger populations, there is gross redundancy of both the anterior and posterior leaflets and chordal apparatus. This is the extreme form of myoxomatous degeneration, known as Barlow’s syndrome. In older populations, however, MVP is characterized by fibroelastic deficiency, sometimes with superimposed chordal rupture due to a lack of connective tissue support. These anatomic abnormalities result in malcoaptation of mitral valve leaflets during systole, resulting in regurgitation. Mitral annular dilatation may also develop over time, resulting in further progression of mitral regurgitation (MR). Acute severe MR results in congestive heart failure symptoms without left ventricular dilatation. Conversely, chronic or progressively severe MR can lead to ventricular dilatation and dysfunction, neurohormonal activation, and heart failure. Elevation in left atrial pressures can result in left atrial enlargement, atrial fibrillation, pulmonary congestion, and pulmonary hypertension. [7]

Myxomatous proliferation is the most common pathologic basis for MVP, and it can lead to myxomatous degeneration of the loose spongiosa and fragmentation of the collagen fibrils. Disruption of the endothelium may predispose patients to infectious endocarditis and thromboembolic complications. However, the vast majority of patients with MVP have only a minor derangement of the mitral valve structure that is usually clinically insignificant.

Mitral valve prolapse (MVP) usually occurs as an isolated entity. It also commonly occurs with heritable disorders of connective tissue, including Marfan syndromeEhlers-Danlos syndrome, osteogenesis imperfecta, and pseudoxanthoma elasticum. [8, 9]  MVP has also been described in association with a secundum atrial septal defect and hypertrophic cardiomyopathy. Also see Presentation.

Mitral valve prolapse (MVP) is thought to be inherited with increased expression of the gene in female individuals (2:1). The most common form of inheritance is autosomal dominant, but X-linked inheritance has been described.

MVP commonly occurs with heritable connective tissue disorders, including Marfan syndromeEhlers-Danlos syndrome, osteogenesis imperfecta, and pseudoxanthoma elasticum. In fact, 75% of patients with Marfan syndrome have MVP due to the increased redundancy of the mitral leaflets and apparatus that occurs as a result of myxomatous degeneration.

In the 1970s and 1980s, MVP was overdiagnosed because of the absence of rigorous echocardiographic criteria, with a reported prevalence of 5-15%. Subsequently, Levine et al reported that the 2-dimensional echocardiographic characterizations of prolapse, especially on the parasternal long-axis view, are most specific for the diagnosis of MVP. Use of these criteria prevents overdiagnosis.

Data from the community-based Framingham Heart Study demonstrated that MVP syndrome occurred in only 2.4% of the population.

MVP has been observed in individuals of all ages.

The prevalence of MVP was similar for men and women in the Framingham Heart Study. [1] However in the Olmsted County population, women were diagnosed more often than men and at a younger age. [10] Complications related to MVP, however, are reported more frequently in men. [11] In a study from Mayo clinic, women presented more commonly with anterior and bileaflet prolapse, fewer flail leaflets, and less mitral regurgitation compared with men. [12] They also undergo mitral surgery less often than men and exhibit excess long-term mortality but equivalent survival after valve surgery compared to men. [12]

Mitral valve prolapse (MVP) has a widely varying prognostic spectrum, although most patients with MVP remain asymptomatic and have a near-normal life expectancy. Approximately 5-10% have progression to severe mitral regurgitation (MR). [13, 14]  Overall, young patients (age >50 years) with normal left ventricular function and no symptoms tend to have excellent survival with medical treatment, even those with severe MR. [10, 15]

Most patients with MVP are asymptomatic and have a benign prognosis, with survival rates similar to those of the general population. Nonetheless, high-risk patients (ie, those with moderate-to-severe MR and reduced left ventricular systolic function) have increased cardiac morbidity and mortality rates. In a community-based study of 833 individuals diagnosed with asymptomatic MVP who were followed up longitudinally in Olmsted County, Minnesota, [16]  the best predictors for cardiac mortality were the presence of MR and left ventricular dysfunction at the time of diagnosis. The study also identified certain risk factors for cardiac morbidity (defined as the occurrence of heart failure, thromboembolic events, atrial fibrillation, or need for cardiac surgery), including age older 50 years, left atrial enlargement, degree of regurgitation, the presence of a flail leaflet, and the presence of  trial fibrillation at the time of the baseline echocardiogram. [16]

Complications of MVP include the following:

Severe MR

Atrial fibrillation

Infective endocarditis

Sudden cardiac death and cerebrovascular ischemic events

Mitral regurgitation (MR)

This is the most common complication of MVP and the leading cause of isolated MR requiring mitral valve surgery in the United States. Severe MR is most frequently due to rupture of the chordae tendineae.

The risk of MR increases with the following factors: age older than 50 years, male sex, history of hypertension, increased body mass index (BMI), increased mitral valve thickness or redundancy, and left atrial and left ventricular dilatation.

In a Mayo clinic series, MR volume increased more than 8 mL in 51% of 74 patients with MVP over a follow-up period of 1.5 years. [17] Progression of the valvular lesions and an increase in mitral annular diameter were the two independent  predictors of an increase in regurgitant volume over time. [17] MR diagnosed on the basis of the presence of a systolic murmur is associated with an increased risk of adverse events, including progressive valve dysfunction, [18, 19, 20] infective endocarditis, [18, 21] and sudden death. [22, 23]

Infective endocarditis

The main mechanism for increased risk is a turbulent flow state due to leaflet thickness or redundancy and MR. The risk of endocarditis increases 3- to 8-fold with MVP. The risk of developing infective endocarditis is higher if a systolic murmur of MR is present. [24]

The main predictors are age older than 50 years, male sex, history of hypertension, increased body mass index (BMI), left atrial and ventricular enlargement, and increased mitral valve thickness or redundancy.

In a systematic review of 287 patients undergoing surgery for native valve endocarditis at the Mayo Clinic, MVP was present in 43% of patients and it was an independent risk factor for development of endocarditis. [25]

Sudden cardiac death (SCD) and cerebrovascular ischemic events

There is a 50-60% increased risk of atrial and ventricular arrhythmias in patients with myxomatous MVP;  the risk of sudden death is 0.4-2% in these patients. [26, 27, 28] The risk is increased when patients have evidence of left ventricular dilatation and dysfunction, severe MR, or increased mitral leaflet thickness or redundancy.

A clinical syndrome of bileaflet MVP syndrome has been described, characterized by myxomatous bileaflet MVP, T-wave inversion in the inferolateral electrocardiograph (ECG) leads, and complex ventricular ectopy (arising from one or both of the papillary muscles), most often observed in young women. [29] In a registry study of 650 adults younger than years with SCD, 43 patients were identified with MVP, comprising 7% of all patients with SCD. [30] Bileaflet involvement was seen in 70%. All patients had left ventricular fibrosis at the level of the papillary muscle on histology and 88% had inferobasal fibrosis. ECGs for 12 of those patients showed right bundle-branch block. Factors cited as increasing the risk for life-threatening ventricular arrhythmias include bileaflet MVP, female sex, and frequent ventricular ectopy. [29]

In the presence of QT prolongation and frequent ventricular ectopy, especially nonsustained ventricular or sustained ventricular tachycardia, an electrophysiologic study may be indicated to quantitate the risk of inducible ventricular tachycardia and/or ventricular fibrillation and sudden arrhythmic death.

There is only a weak relationship between MVP and stroke. In a study of 777 patients with MVP who were followed for a mean period of 5.5 years, ischemic neurologic events occurred in 4% (n = 30). [31] The risk was significantly increased compared to the expected rate in the community. However, the risk was nondetectable in patients with MVP without leaflet thickening but high after either atrial fibrillation or cardiac surgery. [31] Other studies on MVP have found no relationship between MVP and cerebral events. [1] Gilon et al described the lack of an association between MVP and stroke in young 213 patients. [32]

The potential mechanisms for stroke in patients with MVP is related to the prevalence of other risk factors, primarily atrial fibrillation, which may be paroxysmal or asymptomatic. Other hypothesized mechanisms include the formation of platelet fibrin thrombi on the denuded, damaged myxomatous valves resulting in embolization. Data suggest that the prevalence of this mechanism is based on the degree of MR. Abnormal platelet function has also been reported in some studies. [33]

The major risk factors for cerebrovascular events include age older than 50 years, thickened mitral valve leaflets, atrial fibrillation, and a need for mitral valve surgery.

Patients with mitral valve prolapse (MVP) should receive education regarding their prognosis along with the signs and symptoms of disease progression.

Of emphasis, most patients with MVP have a benign course, but the risk of ruptured chordae tendinae and/or clinically significant mitral regurgitation, infective endocarditis, embolic transient ischemic attack (TIA) or stroke, and rare sudden death must also be discussed.

For patient education resources, see Heart Health Center as well as Mitral Valve Prolapse.

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Qurat-ul-ain Jelani, MD Fellow, Department of Medicine, Division of Cardiology, Bridgeport Hospital, Yale New Haven Health System

Qurat-ul-ain Jelani, MD is a member of the following medical societies: American Physician Scientists Association

Disclosure: Nothing to disclose.

Adam E Schussheim, MD Cardiac Specialists, PC

Adam E Schussheim, MD is a member of the following medical societies: American College of Cardiology, American Society of Echocardiography, American Society of Hypertension, American Society of Nuclear Cardiology

Disclosure: Nothing to disclose.

Bhavik V Thakkar, MD Medical Director, Internal Medicine Hospitalist, AppleCare Medical Group

Bhavik V Thakkar, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Heart Association, American Medical Association, Minnesota Medical Association, American Stroke Association, Society for Vascular Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Richard A Lange, MD, MBA President, Texas Tech University Health Sciences Center, Dean, Paul L Foster School of Medicine

Richard A Lange, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, Association of Subspecialty Professors

Disclosure: Nothing to disclose.

Justin D Pearlman, MD, ME, PhD, FACC, MA Chief, Division of Cardiology, Director of Cardiology Consultative Service, Director of Cardiology Clinic Service, Director of Cardiology Non-Invasive Laboratory, Chair of Institutional Review Board, University of California, Los Angeles, David Geffen School of Medicine

Justin D Pearlman, MD, ME, PhD, FACC, MA is a member of the following medical societies: American College of Cardiology, International Society for Magnetic Resonance in Medicine, American College of Physicians, American Federation for Medical Research, Radiological Society of North America

Disclosure: Nothing to disclose.

Alan D Forker, MD Professor of Medicine, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research, MidAmerica Heart Institute of St Luke’s Hospital

Disclosure: Nothing to disclose.

Mitral Valve Prolapse

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