Mitral Valve Prolapse

Key Features

• Usually asymptomatic

• When symptoms are present, they include

  • Nonspecific chest pain

  • Dyspnea

  • Fatigue

  • Palpitations

• Most patients are young, female, thin, and some have minor chest wall deformities

• The significance of mitral valve prolapse (MVP) has been disputed because it is diagnosed by echocardiography frequently in healthy young women (up to 10%)

• Often only one cusp of the mitral valve prolapses (most commonly the middle cusp of the posterior leaflet)

• When multiple cusps of both leaflets prolapse, the valve anatomy is often called Barlow disease

• In occasional patients, MVP is not benign

Clinical Findings

• One or more characteristic midsystolic clicks often—but not always—followed by a late systolic murmur

• Findings are accentuated in the standing position or during the Valsalva maneuver

• A single midsystolic click is usually benign

• The late or pansystolic murmur may presage significant mitral regurgitation, often resulting from rupture of chordae tendineae

Diagnosis

• The diagnosis is primarily clinical and confirmed by Doppler echocardiography

• Evidence of a dilated aorta on chest radiograph should prompt either CT or MRI angiography

• If palpitations are an issue, an ambulatory monitor is often helpful to distinguish atrial from ventricular tachyarrhythmias

Treatment

• Beta-blockers in low doses

  • Used to treat the hyperadrenergic state when present

  • Usually satisfactorily treat arrhythmias

• Selective serotonin reuptake inhibitors have been used, especially if anxiety or orthostatic hypotension is associated, but results have been mixed

• Aspirin was advocated in the past due to concern regarding systemic emboli, but has been abandoned unless there is evidence for atrial tachyarrhythmias

• Mitral valve repair is strongly favored over valve replacement

• The Alfieri procedure

  • Involves stitching the middle of the leaflets together to create a double-orifice mitral valve

  • Can be performed percutaneously (MitraClip)

• Mitral repair or replacement can be done through a right minithoracotomy

• Endocarditis prophylaxis is not recommended for most situations