2. Mitral Valve Prolapse and Regurgitation
Jason Infeld, MD, FACC
Stern Cardiovascular Foundation

3. Stern Cardiovascular Foundation
DISCLOSURE
Jason Infeld
MD, FACC
Stern Cardiovascular Foundation
I have the following personal financial relationships with commercial interests to disclose:
NONE

4. Mitral Valve Prolapse (MVP)
MVP is the most common cause of mitral regurgitation and of congenital valvular heart disease in adults
Definition and diagnostic criteria have changed leading to significant controversy
Many common perceptions about this disease have been recently been shown to be false
Disease was widely overdiagnosed in the 70’s and 80’s as echocardiography became more widely available 4

5. What is MVP?
Systolic bowing of one or both mitral valve leaflets across the plane of the mitral valve annulus into the LA
Disease is often benign, but may be associated severe complications including mitral regurgitation, endocarditis, and arrythmias. 5

6. Classic Mitral-Valve Prolapse during Systole
Figure 1. Classic Mitral-Valve Prolapse during Systole.
The parasternal long-axis view shows the mitral leaflets prolapsing (>2 mm), as indicated by the dotted line, into the left atrium during systole. LA denotes left atrium, and LV left ventricle.
Freed L et al. N Engl J Med 1999;341:1-7

7. Classic Mitral-Valve Prolapse with Leaflet Thickening (Arrows) during Diastole
Figure 2. Classic Mitral-Valve Prolapse with Leaflet Thickening (Arrows) during Diastole.
The parasternal long-axis view demonstrates mitral-leaflet thickening (>=5 mm) during diastole. LA denotes left atrium, and LV left ventricle.
Freed L et al. N Engl J Med 1999;341:1-7

8. How common is MVP?
Early prevalence estimates between 5 and 20% and up to 35% in some studies
Disease was thought to be more common in young women
Studies were faulty due to severe selection bias and a lack of clear echocardiographic criteria 8

9. History of MVP
Described accurately in the 60’s by Barlow in a group of patients with midsystolic clicks and mitral regurgitation seen during cardiac catheterization. Diagnosis was rare.
1970 – first description of M-mode echocardiographic findings.
Echo led to sudden dramatic increase in the diagnosis of this entity
Early studies shows prevalence as high as 35%
“Mitral valve fiasco”

10. History of MVP 1980’s widespread use of 2- dimensional echo
Use of apical 4-chamber view continued to lead to significant overdiagnosis
1987 – study published demonstrating the normal shape of the mitral valve as a “saddle” and that the 4-chamber view should not be used to make the diagnosis

11. Prevalence Framingham study - prevalence approximately 1.1%
Reviewed echos of 3591 men and women
5 to 1 ratio of self-reported diagnosis of MVP and echocardiographic MVP
Prevalence equal between men and women
MVP patients were thinner and had more MR
Average amount of MR was trace to mild 11

12. Echocardiography
Apical 4-chamber view
Parasternal Long-axis View 12

13. 13

15. Leaflet displacement Leaflet thickening
Greater than 2mm above the plane of the mitral annulus in the parasternal long-axis view
Leaflet thickening
Greater than 5mm in the midportion of the anterior mitral leaflet 15

16. Echocardiography Classical vs. nonclassic MVP
>2mm displacement and >5mm thickness are considered to have classic MVP
Patients with leaflet thickeness <5mm have nonclassic MVP
Symmetric vs Asymmetric prolapse 16

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18. Diagnostic Pitfalls Non-specific echo findings M-mode
Apical 4-chamber view
Physical exam. Midsystolic clicks are common in normal individuals.
Symptoms: non-specific with significant overlap with other disease processes 18

19. Natural History of MVP
MVP is generally benign, but serious complications do occur
Complications of MVP are infective endocarditis, cerebrovascular accidents, atrial fibrillation, the need for mitral valve surgery, and death
Complication rates are between 1 and 4% annually
Complication rates vary amongst studies due to referral bias of the most serious cases to tertiary centers and maybe lower than reported
Complications can be predicted by understanding simple risk factors 19

20. Complications Primary risk factors(RFs) for complications
Moderate to severe MR
EF less than 50% 20

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22. Complications Secondary risk factors Slight MR
Left atrial dimension > 40 mm
Flail leaflet
Atrial fibrillation (AF)
Age >50 years. 22

24. 2006 ACC/AHA Guidelines
Repeat echocardiography at yearly intervals in patients with high-risk findings on the initial echocardiogram (eg, diffuse thickening of the mitral leaflets and redundancy), or moderate MR.
Clinical evaluation and repeat echocardiography every 6 to 12 months in patients with severe MR
Clinical evaluation and echocardiography at any time there is a change in signs of symptoms. 24

25. Treatment of MVP

26. Endocarditis Prophylaxis
The 2007 American Heart Association (AHA) guideline for the prevention of infective endocarditis made major revisions to the AHA guideline.
MVP with mitral regurgitation is no longer considered a high risk valve lesion and prophylaxis is no longer recommended.
Although MVP is associated with an increased risk of endocarditis, there are no convincing data that antibiotic prophylaxis is effective in preventing episodes of endocarditis

27. Treatment and F/u of MR 27

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30. Chronic Mitral Regurgitation
Most patients asymptomatic even with severe MR
Progressive dilatation of the LA and LV.
LA enlargement may result in atrial fibrillation
Moderate to severe MR may eventually result in LV dysfunction and development of CHF
Pulmonary hypertension may occur with associated right ventricular dysfunction.
Typically prolonged asymptomatic interval
Maybe an accelerated phase as a result of ruptured mitral valve chordae leading to progressive left atrial and LV dysfunction and atrial fibrillation

31. Goals of Treatment
Prevent irreversible LV dysfunction, pulmonary HTN, or atrial fibrillation in an asymptomatic patient
Relieve symptoms of dyspnea and fatigue in symptomatic patients
Prevent sudden cardiac death

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35. Mitral Valve Repair vs Replacement

36. Mitral Valve Repair Ideal treatment for mitral regurgitation.
Avoids need for anticoagulation and long-term risks of valve prosthesis
Preserves mitral valve anatomy leading to better post-operative LV function and survival
Repair is surgeon specific and success is highly correlated with volume

37. Mitral Valve Repair
Clinician needs to be able to determine the likelihood of repair
Isolated posterior leaflet prolapse more amenable to repair
Presence of severe anterior leaflet prolapse, severe valve thickening and calcification make repair less likely
TEE is recommended pre-operatively to define pathology and mechanism of MR

38. How is it done?

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41. The Robot 41

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43. Flail Mitral Leaflet
Subset of patients who do clinically worse even in the absence of progressive LV dilatation or dysfunction.
Higher-risk of sudden cardiac death
Referral for early surgical treatment if valve amenable to repair.

44. Flail Mitral Leaflet

45. TEE
Plays an important role in the evaluation of MR due to the proximity of the TEE probe to the LA
TTE can underestimate MR due to shadowing from calcification and prosthetic valves
Defines mechanism and severity of MR
Ideal test to assess if repair is feasible

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51. Questions?