f4afMitral Valve Prolapse

7/31/2019 f4afMitral Valve Prolapse

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Mitral Valve Prolapse

Dr Mohammed Haroon Rashid

Resident, Department Cardiology


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Mitral Valve

Consists of 6 major anatomical

components

Annulus

Leaflets

Chordae tendinae

Papillary muscles

Posterior left atrial wall

Left ventricular free wall


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Structure of mitral valve

Features Description

Annulus Saddle Shaped, 4-6cm2

Leaflets Sail shaped AML & C shaped

PML

Papillary Anterolateral PM at 4 O Clock,

Posteromedial PM at 7 O

Clock position

Chordea Tendinae 120 in number


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Mitral Valve Prolapse:

Introduction

A variable clinical syndrome that results

from a diverse pathogenic mechanisms of

one or more portions of mitral valve

apparatus, valve leaflets, chordae

tendinae, papillary muscle & valveannulus.

Many names:

Systolic click murmur syndrome

Barlow syndrome

Billowing mitral cusp syndrome

Myxomatous mitral valve syndrome

Floppy valve syndrome

Redundant cusp syndrome


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Epidemiology

Prevalence of 2.4% of population

Twice frequent in females than in males

Severe MVP occurs more frequently in

older males (>50yrs)


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Etiology

Primary condition

Familial Autosomal trait

Non familial

Secondary conditions

Heritable disorders of connective tissue


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Classification

Classification of MVP

Mitral Valve Prolapse syndrome

Younger age (20-50)

Predominantly females

Click or click murmur present

Benign long term course

Myxomatous Mitral Valve Disease

Older age- 40-70yr

Predominantly males

Thickened & redundant valve leaflets

Progressive disease, requires surgerySecondary Mitral Valve Prolapse

Marfan syndrome

Hypertrophic cardiomyopathy

Ehlers-Danlos syndrome

Other connective tissue disorders


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Pathology

Myxomatous proliferation of mitral valve

leaflets & quantity of acid

mucopolysaccharide is increased.

Regions of endothelial disruption are

common & possible site for thrombus

formation or endocarditis.

Degeneration of collagen & myxomatous

changes within the central core of chordae

tendinae causes decrease of tensilestrength & thus rupture


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Clinical Diagnosis

Symptoms

Atypical chest pain

Palpitations

Dyspnea

Fatigue

Syncope

Signs

Asthenic, low body weight

Normal Blood pressure

Orthostatic hypotension

Straight back syndrome


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Auscultation

Mid or late systolic click, heard over apex

Pansystolic murmur present if associated

with severe mitral regurgitation

Dynamic auscultation Change in loudness as well as the time of

occurrence of both click & murmur are

diagnostic


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Echocardiography

Confirmatory

Prolapse of mitral leaflet into left atrium

Thickening of mitral valve (>5mm)


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Other diagnostic tests ECG

Negative or biphasic t waves & nonspecific ST

changes in leads II, III, aVF & occasionallyanterolateral leads

Arrhythmias

Atrial or Ventricular PC

PSVT (most common) & ventricular

tachyarrhythmia Bradyarrhytmias due to sinus node

dysfunction

Varying degrees of AV blocks

Incidence with WPW & MVP has increased

Increased association with Long QT

syndrome

Mechanism of arrhythmia not clear, but diastolic

depolarization of muscle fibers in anterior mitral

leaflet in response to stretch has been

demonstrated experimentally


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Other diagnostic tests

Stress scintigraphy

Differentiate MVP with IHD

Angiography


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Disease course

General outcome is excellent, large group

remain asymptomatic

Serious complications occur in 1/100

patient years

4% died during 8yrs

Most of the risk factors were based on

severity of MR , ejection fraction (40mm), age

(>50yr)

Risk of development of IE is greater in

men >50yrs


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Predictors of clinical outcomes in

MVP


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Sudden Cardiac Death

Relation of SCD & MVP is not clear

Evidence suggests that MVP increases

the risk of SCD slightly, especially in

patients with severe MR or severe

valvular deformity, & those with

complex ventricular arrhythmias, QT

prolongation is higher.


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Other complications

CNS

Acute hemiplegia

TIAs

Amaurosis fugax

Cerebellar infarcts

Unexplained stroke of young!


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Management

Transesophageal echo in first degree

should be done (Circulation 2005)

Echo should confirm the diagnosis

Asymptomatic patients withoutarrhythmias/IE should be reassured &

follow up examination every 3 to 5yrs to be

done (follow up with color doppler)

Patients with palpitations, arrhythmias

should undergo EP study to characterize

arrhythmias & RF if necessary for AV

bypass tracts in prolonged SVT episodes


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Management Beta blockers for palpitations secondary to

PVCs & relieve chest discomfort

Aspirin in documented cases ofneurological event or if atrial thrombus

exists (Hayek; Mitral valve prolapse. Lancet. 2005 Feb 5-11;365(9458):507-18)

Patients with severe MR & MVP mayrequire MV surgical repair.

Antibiotic prophylaxis for GI & GU

procedures (NICE Clinical Guideline (March 2008)


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Thank You !

f4afMitral Valve Prolapse

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