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.
Signs and Symptoms
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:
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:
Atypical chest pain
Syncope or presyncope
Common general physical features associated with MVP include the following:
Asthenic body habitus
Low body weight or BMI
Scoliosis or kyphosis
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