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Mitral Valve Prolapse

Practice Essentials

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:

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.

Diagnosis

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.

Management

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.

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