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Mitral valve prolapse

Updated : May 17, 2024





Background

In mitral valve prolapse, the cusps of the mitral valve are abnormal. Instead of closing evenly, one or both of the valve’s cusps bulge or billow back into the left atrium when the heart contracts. This condition is often due to excess tissue or a weakened valve structure. MVP is typically a benign condition, and many individuals do not experience any symptoms or complications.

Although MVP is usually not a severe condition, it can lead to complications in some cases. One potential complication is mitral valve regurgitation, where blood flows backward into the left atrium. Severe mitral regurgitation can lead to heart problems over time. Other complications can include infective endocarditis and arrhythmias.

Epidemiology

Mitral valve prolapse is a relatively common heart valve disorder. Its prevalence varies by population, age, and gender. Estimates suggest that it is present in about 2-3% of the general population. It is one of the most frequent valve disorders seen in clinical practice. Mitral valve prolapse can affect people of all ages, but it is most commonly diagnosed in young to middle-aged adults.

Women are more commonly affected by MVP than men, with a female-to-male ratio of approximately 2:1. The reasons for this gender difference are not entirely understood. The prevalence of MVP can vary among different ethnic and racial groups. It appears to be more common in some populations, such as those of Northern European descent, and less common in others. There is evidence to suggest that MVP can run in families, indicating a genetic component to the condition.

Anatomy

Pathophysiology

In mitral valve prolapse, the mitral valve cusps are structurally abnormal. They are often thicker, larger, and more elastic than normal. The underlying pathology is often described as myxomatous degeneration. This refers to the changes in the composition of the valve tissue, with an increase in mucopolysaccharides and a decrease in collagen and elastin.

These alterations affect the strength and flexibility of the valve leaflets. One of the primary consequences of mitral valve prolapse is mitral regurgitation. Mitral regurgitation occurs when the mitral valve fails to close properly during systole, allowing blood to leak backward from the left ventricle into the left atrium.

The regurgitation causes an increased volume of blood in the left atrium, which may lead to atrial enlargement and, in some cases, atrial fibrillation. The left ventricle has to work harder to maintain forward cardiac output, which can lead to left ventricular enlargement and, in severe cases, heart failure.

Etiology

Mitral valve prolapse typically manifests as an independent condition. However, it can also be associated with connective tissue disorders such as Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, osteogenesis imperfecta, aneurysms-osteoarthritis syndrome, and pseudoxanthoma elasticum.

Genetics

Prognostic Factors

Clinical History

Mitral valve prolapse can manifest without noticeable symptoms. However, it may also exhibit various clinical signs, including palpitations, unusual chest discomfort, shortness of breath during physical activity, and reduced exercise tolerance.

Other indications, such as anxiety, fainting episodes, and decreased blood pressure, may imply dysfunction of the autonomic nervous system. In some instances, there is evidence of supraventricular arrhythmias, indicating an elevated parasympathetic influence.

Physical Examination

A mid-systolic click is typically succeeded by a late systolic murmur, often most pronounced at the apex. Notably, the character of the MVP murmur can change with the patient’s position. When the patient is upright or during a Valsalva maneuver, the murmur intensifies (resulting in an earlier systolic click and a more prolonged murmur), while it diminishes when the patient is in a squatting position (leading to a delayed systolic click and a shorter murmur).

It is worth mentioning that the murmur associated with MVP shares similarities with that seen in hypertrophic cardiomyopathy. The presence of a mid-systolic click serves as a diagnostic hallmark of MVP. Additionally, the handgrip maneuver amplifies the MVP murmur and diminishes the murmur characteristic of hypertrophic cardiomyopathy. This maneuver also shortens the duration of the MVP murmur and hinders the timing of the mid-systolic click.

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Mitral Regurgitation

Atrial Fibrillation

Infective Endocarditis

Pulmonary Hypertension

Rheumatic Heart Disease

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

Patients with mitral valve prolapse who remain symptom-free typically do not necessitate any treatment. For individuals with MVP experiencing symptoms related to dysautonomia, such as chest pain or palpitations, the recommended approach is to administer beta-blockers like propranolol. It is important to note that those with MVP face an elevated risk of bacterial endocarditis.

Recent guidelines from the American Heart Association now advise that antibiotic precaution for dental procedures is warranted only for patients with other concurrent cardiac conditions that place them at the highest risk of complications from infective endocarditis. In cases where there is echocardiographic evidence of high-risk MVP in patients with a normal heart rhythm, aspirin may be considered.

Anticoagulation therapy is recommended if there is a history of systemic embolism or recurrent transient ischemic attacks (TIAs) despite aspirin therapy. However, anticoagulants are not advocated in the absence of systemic embolism, ischemic stroke, unexplained TIAs, or atrial fibrillation. Asymptomatic patients with MVP are typically managed conservatively, involving regular monitoring.

Those without concurrent mitral regurgitation may be monitored every 3 to 5 years, while those with mitral regurgitation should be monitored annually. If symptomatic patients present with anxiety, palpitations, or chest pain, it is essential to explore other potential causes. For patients with systolic heart failure, severe mitral regurgitation, and progressive symptoms, surgical intervention is required.

Even asymptomatic patients with MVP and mitral regurgitation in the presence of systolic heart failure may be considered for surgery. Mitral valve repair is the preferred procedure over mitral valve replacement. In situations where symptomatic patients have significant comorbidities that make surgery a high-risk endeavor, transcatheter mitral valve repair may be a viable option to explore.

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

Medication

Media Gallary

References

Mitral valve prolapse

Updated : May 17, 2024




In mitral valve prolapse, the cusps of the mitral valve are abnormal. Instead of closing evenly, one or both of the valve’s cusps bulge or billow back into the left atrium when the heart contracts. This condition is often due to excess tissue or a weakened valve structure. MVP is typically a benign condition, and many individuals do not experience any symptoms or complications.

Although MVP is usually not a severe condition, it can lead to complications in some cases. One potential complication is mitral valve regurgitation, where blood flows backward into the left atrium. Severe mitral regurgitation can lead to heart problems over time. Other complications can include infective endocarditis and arrhythmias.

Mitral valve prolapse is a relatively common heart valve disorder. Its prevalence varies by population, age, and gender. Estimates suggest that it is present in about 2-3% of the general population. It is one of the most frequent valve disorders seen in clinical practice. Mitral valve prolapse can affect people of all ages, but it is most commonly diagnosed in young to middle-aged adults.

Women are more commonly affected by MVP than men, with a female-to-male ratio of approximately 2:1. The reasons for this gender difference are not entirely understood. The prevalence of MVP can vary among different ethnic and racial groups. It appears to be more common in some populations, such as those of Northern European descent, and less common in others. There is evidence to suggest that MVP can run in families, indicating a genetic component to the condition.

In mitral valve prolapse, the mitral valve cusps are structurally abnormal. They are often thicker, larger, and more elastic than normal. The underlying pathology is often described as myxomatous degeneration. This refers to the changes in the composition of the valve tissue, with an increase in mucopolysaccharides and a decrease in collagen and elastin.

These alterations affect the strength and flexibility of the valve leaflets. One of the primary consequences of mitral valve prolapse is mitral regurgitation. Mitral regurgitation occurs when the mitral valve fails to close properly during systole, allowing blood to leak backward from the left ventricle into the left atrium.

The regurgitation causes an increased volume of blood in the left atrium, which may lead to atrial enlargement and, in some cases, atrial fibrillation. The left ventricle has to work harder to maintain forward cardiac output, which can lead to left ventricular enlargement and, in severe cases, heart failure.

Mitral valve prolapse typically manifests as an independent condition. However, it can also be associated with connective tissue disorders such as Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome, osteogenesis imperfecta, aneurysms-osteoarthritis syndrome, and pseudoxanthoma elasticum.

Mitral valve prolapse can manifest without noticeable symptoms. However, it may also exhibit various clinical signs, including palpitations, unusual chest discomfort, shortness of breath during physical activity, and reduced exercise tolerance.

Other indications, such as anxiety, fainting episodes, and decreased blood pressure, may imply dysfunction of the autonomic nervous system. In some instances, there is evidence of supraventricular arrhythmias, indicating an elevated parasympathetic influence.

A mid-systolic click is typically succeeded by a late systolic murmur, often most pronounced at the apex. Notably, the character of the MVP murmur can change with the patient’s position. When the patient is upright or during a Valsalva maneuver, the murmur intensifies (resulting in an earlier systolic click and a more prolonged murmur), while it diminishes when the patient is in a squatting position (leading to a delayed systolic click and a shorter murmur).

It is worth mentioning that the murmur associated with MVP shares similarities with that seen in hypertrophic cardiomyopathy. The presence of a mid-systolic click serves as a diagnostic hallmark of MVP. Additionally, the handgrip maneuver amplifies the MVP murmur and diminishes the murmur characteristic of hypertrophic cardiomyopathy. This maneuver also shortens the duration of the MVP murmur and hinders the timing of the mid-systolic click.

Mitral Regurgitation

Atrial Fibrillation

Infective Endocarditis

Pulmonary Hypertension

Rheumatic Heart Disease

Patients with mitral valve prolapse who remain symptom-free typically do not necessitate any treatment. For individuals with MVP experiencing symptoms related to dysautonomia, such as chest pain or palpitations, the recommended approach is to administer beta-blockers like propranolol. It is important to note that those with MVP face an elevated risk of bacterial endocarditis.

Recent guidelines from the American Heart Association now advise that antibiotic precaution for dental procedures is warranted only for patients with other concurrent cardiac conditions that place them at the highest risk of complications from infective endocarditis. In cases where there is echocardiographic evidence of high-risk MVP in patients with a normal heart rhythm, aspirin may be considered.

Anticoagulation therapy is recommended if there is a history of systemic embolism or recurrent transient ischemic attacks (TIAs) despite aspirin therapy. However, anticoagulants are not advocated in the absence of systemic embolism, ischemic stroke, unexplained TIAs, or atrial fibrillation. Asymptomatic patients with MVP are typically managed conservatively, involving regular monitoring.

Those without concurrent mitral regurgitation may be monitored every 3 to 5 years, while those with mitral regurgitation should be monitored annually. If symptomatic patients present with anxiety, palpitations, or chest pain, it is essential to explore other potential causes. For patients with systolic heart failure, severe mitral regurgitation, and progressive symptoms, surgical intervention is required.

Even asymptomatic patients with MVP and mitral regurgitation in the presence of systolic heart failure may be considered for surgery. Mitral valve repair is the preferred procedure over mitral valve replacement. In situations where symptomatic patients have significant comorbidities that make surgery a high-risk endeavor, transcatheter mitral valve repair may be a viable option to explore.