Clinical and exercise echocardiographic findings in patients with mitral valve prolapse

To assess the relationship between left ventricular functional reserve and prognosis in patients with idiopathic mitral valve prolapse, ergometer exercise echocardiography was performed in 10 normal subjects and 30 patients with mitral valve prolapse having either mild, or no mitral regurgitation. These 30 patients with mitral prolapse were followed for 2 to 8 (mean 4.5) years. Increment of % fractional shortening during maximum exercise at the initial study in patients with mitral valve prolapse and normal subjects were 7 +/- 7 and 11 +/- 3%, respectively. Based on increment of % fractional shortening, patients with mitral valve prolapse were divided into 2 groups; Group I: 13 cases with delta% fractional shortening less than 5%, Group II: 17 cases with delta% fractional shortening greater than or equal to 5%. The incidence of cardiac symptoms was higher in Group I than in Group II (85 vs 41%, p less than 0.05). ST-T changes and life-threatening arrhythmias were more frequently observed in Group I. During the follow-up period, M-mode echocardiographic measurements did not vary in Group II, but left ventricular and left atrial dimensions increased significantly (p less than 0.05, p less than 0.01, respectively) and % fractional shortening decreased significantly (p less than 0.01) in Group I without any change in mitral regurgitation severity. Thus, some patients with mitral valve prolapse not having significant mitral regurgitation may develop progressive deterioration of the cardiac function, which may be predicted by exercise echocardiography.     

Clinical significance of the echocardiographic degree of mitral valve prolapse

To assess the clinical significance of the echocardiographic degree of mitral valve prolapse, we prospectively evaluated with Doppler echocardiography 245 consecutive patients referred with signs or symptoms consistent with a diagnosis of mitral valve prolapse. The echocardiographic degree of mitral valve prolapse was measured by a scoring system that incorporates an assessment of mitral systolic displacement from the M-mode as well as the two-dimensional long-axis and apical four-chamber views (range 0 to 9, 0 = no mitral valve prolapse). A structured questionnaire was used to record the frequency and severity of symptoms. Pulsed and continuous-wave Doppler echocardiography were performed to document mitral regurgitation and determine the ratio of peak early to atrial diastolic filling velocities. Patients were grouped according to the degree of mitral valve prolapse; 45 patients had no echocardiographic evidence of mitral valve prolapse. There was no statistically significant relationship between the mitral valve prolapse score and symptoms or left ventricular systolic or diastolic function. There was, however, a strong relationship between the echocardiographic degree of mitral valve prolapse and the presence of significant mitral regurgitation. Patients without echocardiographic evidence of mitral valve prolapse had a 4% incidence of mitral regurgitation, which was not significantly different than that of persons with mild degrees of prolapse (6%). However, the groups with the most marked degree of prolapse (scores of 6, 7, 8, and 9) had a significantly higher incidence of mitral regurgitation (20% and 60% respectively, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

The echocardiographic association of mitral valve prolapse and mitral anulus calcification

Mitral anulus calcification (MAC) and mitral valve prolapse (MVP) are frequently diagnosed conditions. We studied two patients with mild or moderate mitral regurgitation who demonstrated both MAC and MVP on angiography and echocardiography. M-mode echocardiography is probably the definitive test for confirming the presence of MVP. Echocardiography is moderately sensitive in the diagnosis of cardiac calcification, such as MAC, but M-mode echocardiography may not detect the MAC in the majority of patients with both MVP and MAC demonstrated by angiography.     

Observer variation in the echocardiographic diagnosis of mitral valve prolapse

To assess inter- and intraobserver variation in the echocardiographic diagnosis of mitral valve prolapse, three independent observers analyzed M-mode echocardiograms (n = 80) and two-dimensional echocardiograms (n = 65) of patients with a mobile midsystolic click with or without a late or holosystolic murmur. In addition, a control group of 100 normal echocardiograms were interspersed among the echocardiograms of patients with mitral valve prolapse and were then interpreted. Each of the three observers analyzed all M-mode and two-dimensional echocardiograms initially and then 2 weeks later for the presence or absence of mitral valve prolapse. M-mode echocardiographic criteria for mitral valve prolapse consisted of late systolic posterior motion (greater than or equal to 3 mm) of one or both mitral leaflets or holosystolic hammocking (greater than or equal to 3 mm) of one or both mitral leaflets. Two-dimensional echocardiographic criteria for mitral valve prolapse consisted of: posterior systolic arching of one or both mitral leaflets in the parasternal long-axis view, and/or posterior systolic bowing of one or both mitral leaflets in the apical four-chamber view posterior to the plane of the mitral anulus, and/or excessive posterior coaptation of the mitral leaflets in either view flush with or posterior to the plane of the mitral anulus. There was insignificant observer variation both in the M-mode and two-dimensional echo groups, as determined using Cochran's Q test.(ABSTRACT TRUNCATED AT 250 WORDS)     

The relationship between clinical and echocardiographic findings in mitral valve prolapse

Incorporating prognostically related auscultatory, M-mode, 2DE and recent Doppler echocardiographic features, the following strict criteria for establishing the diagnosis of mitral valve prolapse (MVP) have been advanced: 1. auscultatory; mid-to-late systolic clicks and a late systolic murmur at the apex or mid-to-late systolic clicks at the apex which move appropriately with maneuvers that alter LV volume or late systolic murmur at the apex in young patients (coinciding that a similar murmur in elderly population is non-specific for MVP); 2. two-dimensionally "targeted" M-mode criterion: marked (greater than 3 mm) late systolic buckling posterior to C-D line (moderate 2 mm late systolic buckling or 3 mm holosystolic displacement "arouse suspicion" but do not establish MVP); 3. two-dimensional echocardiographic criteria: severe bowing of leaflet(s) on the parasternal long axis and four-chamber view (mild to moderate bowing alone are unacceptable) or left atrial coaptation point; 4. Doppler echocardiographic criteria: moderate or severe Doppler mitral regurgitation with any degree of leaflet bowing or mild Doppler mitral regurgitation with at least moderate bowing of one leaflet (mild leaflet bowing and mild mitral regurgitation can be regarded as "probable MVP"). The concept of mitral valve prolapse syndrome encompasses that which was earlier described in patients with a high prevalence of symptoms. In controlled studies, however, it has become apparent that cardiac and psychiatric symptoms can be found as frequently in normal subjects as in those with MVP. These results indicate that clinicians may have erroneously diagnosed patients with MVP because of premature acceptance that MVP is the cause of a distinctive syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)     

Isolated cleft of both the anterior and posterior mitral valve leaflets

A 37 year‐old female patient in whom the transthoracic echocardiography examination revealed dilatation of left heart chambers with left ventricular ejection fraction of 30% and moderate‐to‐severe mitral valve regurgitation was admitted to our hospital. On 2DTEE examination, mitral valve was normal; however, on 3D images, clefts of both anterior and posterior leaflets were revealed. Isolated cleft mitral valve without any other feature of atrioventricular septal defect is uncommon. 2D echocardiography has limited capability in defining the complex 3D anatomic characteristics of the cleft. 3DTEE allows to visualize the cleft position, morphology, and size, and it is important for surgical planning.     

Three-dimensional echocardiographic reconstruction of the mitral valve, with implications for the diagnosis of mitral valve prolapse

Mitral valve prolapse has been diagnosed by two-dimensional echocardiographic criteria with surprising frequency in the general population, even when preselected normal subjects are examined. In most of these individuals, however, prolapse appears in the apical four-chamber view and is absent in roughly orthogonal long-axis views. Previous studies of in vitro models with nonplanar rings have shown that systolic mitral annular nonplanarity can potentially produce this discrepancy. However, to prove directly that apparent leaflet displacement in a two-dimensional view does not constitute true displacement above the three-dimensional annulus requires reconstruction of the entire mitral valve, including leaflets and annulus. Such reconstruction would also be necessary to explore the complex geometry of the valve and to derive volumetric measures of superior leaflet displacement. A technique was therefore developed and validated in vitro for three-dimensional reconstruction of the entire mitral valve. In this technique, simultaneous real-time acquisition of images and their spatial locations permits reconstruction of a localized structure by minimizing the effects of patient motion and respiration. By applying this method to 15 normal subjects, a coherent mitral valve surface could be reconstructed from intersecting scans. The results confirm mitral annular nonplanarity in systole, with a maximum deviation of 1.4 +/- 0.3 cm from planarity. They directly show that leaflets can appear to ascend above the mitral annulus in the apical four-chamber view, as they did in at least one view in all subjects, without actual leaflet displacement above the entire mitral valve in three dimensions, thereby challenging the diagnosis of prolapse by isolated four-chamber view displacement in otherwise normal individuals. This technique allows us to address a uniquely three-dimensional problem with high resolution and provide new information previously unavailable from the two-dimensional images. This new appreciation should enhance our ability to ask appropriate clinical questions relating mitral valve shape and leaflet displacement to clinical and pathologic consequences.     

Floppy mitral valve, mitral valve prolapse, and mitral valvular regurgitation

Opinion statement  

Colour Doppler echocardiographic assessment of regurgitant flow in mitral valve prolapse

Colour flow mapping was used to examine the pattern of regurgitantflow in 46 patients with mitral regurgitation due to mitralvalve prolapse. Valve morphology was assessed from the real-timetwo-dimensional image and the presence of mitral regurgitationwas determined from real time Doppler. On morphological criteria11 (24%) patients had isolated or predominant anterior leafletprolapse, 22 (48%) patients posterior and 13 (28%) patientsbi-leaflet prolapse. A single regurgitant jet was detected in43 patients (93%) and multiple jets in three (7%). The directionof the regurgitant jet was assessed in multiple views in twoorthogonal planes (antero-posterior and medial-lateral) definedin relation to the mitral valve leaflets. The regurgitant jetwas eccentric in the antero-posterior plane of the mitral leafletsin 40 of 45 (89%) cases and in the medial-lateral plane in 36of 40 (90%) cases. Posterior leaflet prolapse was usually associatedwith antero-medially directed jets, anterior leaflet prolapsewith postero-central or postero-lateral jets and bi-leafletprolapse with predominantly postero-medial jets. In a subgroupof patients with significant mitral regurgitation and an eccentricregurgitant jet, a ‘swirling’ effect was producedwith late systolic flow in the body of the left atrium towardthe mitral valve. Colour flow mapping in patients with mitral regurgitation dueto mitral valve prolapse demonstrated eccentric jets in mostpatients. The direction of regurgitant flow appeared to dependgreatly on the dynamic anatomy of the mitral valve leafletsduring systole. Although a single jet was detected in most patients,multiple jets did occur in a minority.     

Sensitivity and specificity of two-dimensional echocardiographic signs of mitral valve prolapse

The sensitivity and specificity of previously described 2-dimensional echocardiographic signs of mitral valve prolapse (MVP) were assessed in 70 patients with MVP and in 100 normal control subjects. Specificity of individual signs was uniformly high, ranging from 88% for excessive motion of the posterior mitral ring to 100% for several signs including systolic arching in the parasternal long-axis view, excessive posterior coaptation and diastolic doming of the anterior mitral leaflet. Sensitivity of individual signs was low to moderate, ranging from 1% for whip-like motion of both mitral leaflets to 70% for excessive posterior coaptation of the mitral leaflets in the apical 4-chamber view. The highest sensitivity value (87%) was associated with the presence of systolic arching of 1 or both mitral leaflets in the parasternal long-axis view or systolic bowing of 1 or both mitral leaflets in the apical 4-chamber view or excessive posterior coaptation of the mitral leaflets or a combination. This increase in sensitivity was achieved without sacrificing specificity (97%). Thus, the individual 2-dimensional echocardiographic signs tested possess uniformly high specificity, but only low to moderate sensitivity; however, sensitivity can be markedly enhanced without sacrificing specificity by using selected combinations of echocardiographic signs.     

Incidence of mitral valve prolapse in one hundred clinically stable newborn baby girls: an echocardiographic study.

Clinical and echocardiographic examinations were performed on 100 clinically stable, newborn baby girls. Mitral valve prolapse was noted on the echocardiograms of seven babies. Three subjects had systolic clicks, two of whom had systolic murmurs following the click. The four other babies who had echocardiographic evidence of mitral valve prolapse had no abnormal auscultatory signs. Of the 93 babies without evidence of mitral prolapse, 91 had normal echocardiograms and auscultatory features; one was noted to have a murmur consistent with a ventricular septal defect, and another had an eccentric aortic valve on the echocardiogram which was suggestive of a bicuspid aortic valve. Serial studies on our group of subjects will yield useful information regarding the natural history of mitral valve prolapse.     

The gap between mitral leaflets as a cause of mitral regurgitation: relationship to mitral valve prolapse.

The gap between the tips of the anterior and posterior mitral leaflets was studied to assess the significance of this gap in the diagnosis of mitral valve prolapse. The subjects were 39 patients in whom the gap was seen and the mitral valve did not exceed the mitral annular line in systole on two-dimensional echocardiography. Forty eight healthy subjects, in whom phonocardiography disclosed no abnormalities, served as controls. The site of the gap as well as the site and severity of mitral regurgitation were assessed with two-dimensional echocardiography and Doppler flow imaging. The incidence of mitral regurgitation was 82%, which was comparable to that in the controls (67%). The site of the gap was consistent with that of regurgitation. The gap was also seen in a low percentage of healthy subjects, but clinically significant mitral regurgitation did not accompany the gap in healthy subjects including the gap-carrying controls. On the other hand, many of the gap-carrying patients showed clinically significant mitral regurgitation. Also the fact that a gap between the tip of the anterior and posterior mitral leaflets was found to be frequently accompanied by phonocardiographical features corresponding to mitral valve prolapse indicates that the presence of a gap is a significant finding.     

Assessment of prolapsing pattern of the anterior mitral valve in mitral valve prolapse: new echocardiographic diagnostic criteria

In the present study, the ballooning pattern of the anterior mitral valve (AMV) in mitral valve prolapse (MVP) was investigated, and new diagnostic criteria for MVP were established using two-dimensional and Doppler echocardiography. The study population consisted of 164 patients with prolapse of the AMV alone, including 86 patients with idiopathic MVP, 52 associated with atrial septal defect (ASD), 17 having chordal rupture and nine associated with connective tissue disorders. There were 60 normal controls. The results were as follows: 1. The AMV was divided into two zones, clear and rough (CZ and RZ), according to the point of insertion of the strut chordae based on two-dimensional long-axis echocardiograms of the left ventricle. The severity of AMV prolapse was determined by an angle between the posterior aortic wall (PAO)-CZ and the CZ-RZ. a) Type A: Apparently there was a transitional point between CZ and RZ, despite normal PAO-CZ and CZ-RZ angles. The RZ showed mild ballooning or prolapse into the left atrium. b) Type B: Although the PAO-CZ angle was normal, the CZ-RZ angle was markedly narrowed. Therefore, prolapse of the RZ was more severe compared with that of type A. c) Type C: An overall zone of the AMV showed ballooning or prolapse into the left atrium due to a narrowed PAO-CZ angle. 2. Type B prolapse was frequently observed in idiopathic MVP (58%), the ASD group (71%) and the chordal rupture group (71%), and type C prolapse in MVP of connective tissue disorders (89%). 3. All of 18 patients (100%) with type A, 48 of 99 (48%) with type B, and 10 of 47 (21%) with type C could not be diagnosed as MVP using Gilbert's criterion. 4. Doppler mitral regurgitation (MR) was detected in 40 of the 47 patients (85%) with type C in 56 of the 99 (59%) with type B, and in seven of the 18 (39%) with type A. These results suggested that classification of the two-dimensional echocardiography of the AMV into two zones, clear and rough (CZ and RZ), could contribute to determining not only the severity of AMV prolapse, but also to the extent of myxomatous changes of the AMV and to evaluating the correlations between the degree of MVP and the incidence of MR.     

Sensitivity and specificity of M mode echocardiographic signs of mitral valve prolapse

To assess the sensitivity and specificity of previously described M mode echocardiographfc signs of mitral valve prolapse, 100 subjects with a mobile mid systolic click and 100 matched normal control subjects were prospectively studied. Late systolic posterior motion and holosystolic hammocking of the mitral leaflets were common, highly specific signs of mitral valve prolapse. When these signs were combined as a single criterion, sensitivity was 85 percent and specificity was 99 percent. Other signs, including systolic echoes in the mid left atrium, systolic anterior motion, early diastolic anterior motion of the posterior mitral leaflet and shaggy or heavy cascading linear diastolic echoes posterior to the mitral valve, were highly specific but uncommon. They occurred only in combination with late systolic posterior motion or holosystolic hammocking. The remaining signs tested did not differentiate subjects with mitral valve prolapse from normal persons.     

Comparison of echocardiographic methods in assessing severity of mitral regurgitation in patients with mitral valve prolapse

BACKGROUND AND AIM OF THE STUDY: Mitral regurgitation (MR) shows different characteristics in mitral valve prolapse (MVP); hence, it is important to assess MR severity accurately in these patients. The study aim was to compare Doppler echocardiographic methods in making such assessment. METHODS: Forty-seven patients with confirmed MVP and at least moderate mitral insufficiency, as established by Doppler echocardiography, were studied. Quantitative Doppler was used as the reference standard method. Color Doppler mapping was used to determine regurgitant jet area (JA/LAA), flow convergence (EROA-PISA) and vena contracta width (VCW). Systolic pulmonary venous flow reversal (SPVFR) and mitral E-wave velocity were also monitored. RESULTS: Univariate analysis showed severe MR to be significantly correlated to age, presence of atrial fibrillation, left ventricular systolic and diastolic diameter, left atrial diameter, mitral E velocity, JA/LAA, VCW, EROA-PISA and the presence of SPVFR. On multivariate analysis, the strongest determinants of severe MR were EROA-PISA, VCW and E velocity. The greatest area under the receiver-operator curve for diagnosing severe MR was observed with EROA-PISA. The 45-mm2 threshold of EROA-PISA had the highest risk ratio of severe MR with a high sum of sensitivity and specificity. However, the JA/LAA had the lowest risk ratio and negative predictive value for severe MR. CONCLUSION: PISA, VCW, E velocity and SPVFR measurements may be used to evaluate MR severity semi-quantitatively in patients with MVP; however, the ratio of JA/LAA appears to be a less reliable method in this respect.