Mitral valve prolapse in patients with pure rheumatic mitral stenosis: an angiographic study

Of 122 adult patients suspected of having rheumatic mitral stenosis, 112 fulfilled the hemodynamic and angiographic criteria for pure, isolated mitral stenosis. There were 88 females and 24 males with an age range of 16 to 60 years. The left ventriculograms (30 degrees right anterior oblique) were subjectively assessed for gross bulging of the mitral valve leaflets beyond the mitral fulcrum into the left atrium during a beat with maximal opacification. Seventeen percent of cases had typical evidence of mitral valve prolapse, which is much higher than the 3% to 5% rate reported for the general population. This phenomenon was independent of the patients' age, sex, hemodynamic findings, and/or their underlying cardiac rhythm, thus implying the direct role of rheumatic mitral stenosis in the genesis of secondary mitral valve prolapse.     

Mitral valve echoes in patients with mitral valve prolapse syndrome.

Echocardiology is an important tool in diagnosing patients with the mitral valve prolapse (MVP) syndrome. An unusual echocardiographic finding reported in this study was observed in 12 of 83 patients (14.5 per cent) with MVP syndrome. The finding consisted of a pattern of multiple, high-intensity parallel echoes behind the anterior mitral leaflet noted throughout diastole which in character were closely akin to those previously observed in left atrial myxoma or hemodynamically significant flail mitral valve leaflet. These latter diagnoses were excluded by other criteria. The prevalence of this finding in patients with MVP was significantly increased (P < .01 by Chi-square contingency testing) when contrasted with 44 patients without MVP. There was no identifying feature in the clinical history or physical examination which could be used to predict those in whom the diastolic echoes were observed. However, a significant increase in dysrhythmias as recorded by routine electrocardiogram or 24-hour Holter monitoring was noted. Angiographic information obtained in selected patients suggested that the posterior leaflet per se caused these diastolic echoes. Because of patulous transformation of the valve, elongation of the chordae, or loss of support of the papillary muscle from the posterior free wall, the posterior leaflet appeared drawn forward toward the anterior leaflet, perhaps from a venturi-like effect caused by the rapid ingress of blood during diastolic filling. This malpositioning of the posterior leaflet was not associated with significant mitral regurgitation and appears to represent but another facet in the spectrum of mitral valve prolapse.     

Mitral valve prolapse

Mitral valve prolapse is a common valvular abnormality that is the most common cause of severe non-ischaemic mitral regurgitation in the USA. The overall prognosis of patients with mitral valve prolapse is excellent, but a small subset will develop serious complications, including infective endocarditis, sudden cardiac death, and severe mitral regurgitation. We present a comprehensive review of mitral valve prolapse, examining normal mitral anatomy, the clinical and echocardiographic features of mitral valve prolapse, and the pathophysiology and genetics of the disorder. We discuss the contemporary management of both asymptomatic and symptomatic prolapse, with particular attention to the timing and technique of surgical repair. We conclude that echocardiography is the method of choice for diagnosing mitral valve prolapse, that clinical and echocardiographic features can predict which patients with prolapse are at highest risk for complications, and that mitral valve repair is the treatment of choice for symptomatic prolapse.     

Mitral valve prolapse

Mitral valve prolapse has previously been found to be associated with severe cardiovascular complications such as embolic insults, infectious endocarditis, and sudden cardiac death. However, at the same time, in particular after adopting M-mode and 2D echo for diagnosis, prevalence of the disease was found to be very high, especially in the young. The dilemma of a disease which is frequent and mostly asymptomatic, but in some cases has catastrophic complications, has been solved by implementation of more restrictive diagnostic criteria based on an appreciation of the spatial morphology of the mitral annulus. These criteria call for diagnosis exclusively based on long axis views and a prolapse of > 2 mm beyond a line connecting the leaflet insertion points. "Classic prolapse" additionally requires diastolic thickness of the mitral leaflets of at least 5 mm. Two recent studies, a population-based study of mitral valve prolapse prevalence, and a case-control study of juvenile stroke patients compared to a group of young patients without a history of stroke, shed further light on this disease. The authors found that prevalence of mitral valve prolapse in an average population is 2-3% (1.3% for classic prolapse), without age or sex preponderance; the rate of cerebrovascular insults, congestive heart failure, and atrial fibrillation of patients with prolapse does not exceed that of the rest of the population; however, mitral insufficiency is more frequent; young patients with a history of cerebrovascular insult do not have higher mitral valve prolapse rates than young patients without previous insult.     

The relationship between mitral valve prolapse and acute rheumatic fever in pediatric patients.

Mitral valve prolapse (MVP) is a clinical syndrome of which mitral regurgitation and congestive heart failure are the late sequelae. It can be usually diagnosed by echocardiography. In this study, we reevaluated the patients with acute rheumatic fever (ARF) who were followed-up regularly for aspects of MVP. Physical examination, echocardiography and Doppler study were performed for all the patients. One hundred twenty-seven cases of polyarthritis (54.7%), and 105 cases of valvular involvement (45.3%) were diagnosed. Echocardiography demonstrated MVP in 46.8% with isolated mitral insufficiency, in 38.2% with combined valvular defect and in 12.6% with only polyarthritis. One hundred healthy children comprised the control group. Statistical analyses revealed a significant difference in favor of valvular involvement between the groups.     

Mitral valve prolapse in patients with surgically-closed atrial septal defect

To evaluate the prevalence, causes and clinical significance of mitral valve prolapse (MVP) associated with surgically-closed atrial septal defect (ASD), 90 patients (M: 41, F: 49) were studied using two-dimensional and color-coded Doppler echocardiography. Among the 90 patients, preoperative echocardiograms were available in 27. MVP was found in 21 of the 27 patients (78%) preoperatively, but it was found in 59% (16/27) postoperatively. In total, MVP was detected in 50 of the 90 patients (56%) postoperatively. The postoperative MVP group had higher pulmonary-to-systemic flow ratios (3.6 +/- 1.9 vs 2.8 +/- 1.1, p less than 0.05) and higher mean pulmonary arterial pressures (21 +/- 11 vs 13 +/- 5 mmHg, p less than 0.01) at the time of surgery. Between the two groups with or without MVP postoperatively, there was no difference (p less than 0.05) in age at surgery, the postoperative duration and left ventricular (LV) deformity index both in pre- and postoperative states. A mitral regurgitant (MR) murmur was recorded in seven patients postoperatively. However, only two had clinically severe MR. It was concluded that MVP is frequently detected in patients with closure of ASD and it is related neither to degree of the LV deformity nor to age at operation; rather, it is related to the severity of the preoperative hemodynamic state. Clinically significant MR is rare in the postoperative period.     

Mitral valve prolapse in patients with anorexia nervosa and bulimia

We studied 43 consecutive individuals with eating disorders (anorexia nervosa and/or bulimia) for the presence of mitral valve prolapse and/or cardiac arrhythmias by physical examination, M-mode and two-dimensional echocardiography, and 24-hour continuous ambulatory electrocardiographic monitoring. Ten of the 43 had findings of mitral valve prolapse on resting cardiac auscultation. Echocardiographic evaluation confirmed the diagnosis of mitral valve prolapse in these ten as well as in six other individuals, giving an overall incidence of 37% (16/43). Similar echocardiographic findings were present in only 4% (1/23) of control individuals. Cardiac arrhythmias other than benign isolated premature extrasystoles were noted in five patients with eating disorder; all five also had echocardiographic findings of mitral valve prolapse. The incidence of mitral valve prolapse appears to be increased in patients with eating disorders. In addition, the arrhythmogenic effects of mitral valve prolapse may present an additional risk factor in these patients.