Complex arrhythmias in mitral regurgitation with and without mitral valve prolapse: Contrast to arrhythmias in mitral valve prolapse without mitral regurgitation

Atrial and ventricular arrhythmias were characterized by ambulatory electrocardiography in 31 patients with nonischemic mitral regurgitation (MR), 17 of whom had echocardlographic evidence of mitral valve prolapse (MVP) and 14 of whom had other causes of MR. Frequent and complex arrhythmias were common and equally prevalent in each MR subgroup, whether or not MVP was present. Multiform ventricular ectopy was found in 77%% (24 of 31), ventricular couplets in 61 % (19 of 31), and ventricular salvos or ventricular tachycardia in 35% (11 of 31) of patients with MR. Arrhythmias in patients with MR were significantly more prevalent than in 63 patients with MVP who had no evidence of MR. Among patients with MVP, excess arrhythmias associated with MR were most striking with respect to frequent ventricular premature complexes (41 % with MR vs 3 % without MR), multiform ventricular ectopic activity (88% vs 43%), ventricular couplets (65% vs 6%), and ventricular salvos or ventricular tachycardia (35 vs 5 %) (p <0.005 for each comparison). These data demonstrate that complex arrhythmias are common in patients with nonischemic MR irrespective of etiology, and that these arrhythmias are more strongly associated with hemodynamically important MR than with MVP alone.     

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

Opinion statement  

Progression of mitral regurgitation in patients with mitral valve prolapse

Mitral valve prolapse (MVP) is a very common clinical entity which is frequently associated with mild mitral regurgitation (MR) and which most commonly becomes clinically manifest in the third and fourth decades of life. Severe MR associated with MVP, occurs much less frequently and is most commonly seen in patients above the age of 50 years. Relatively little information is available regarding the progression of mild to severe MR in patients with MVP. This report reviews a recent study which investigated the progression from mild to severe MR in patients with MVP. The study included 86 patients, average age 60 years, who presented with cardiac symptoms and severe MR. A high incidence of MVP was seen on echocardiograms (57 of 75 [75%]) and on left ventriculography (61 of 84 [73%]). Mitral valve replacement was performed in 75 patients. Pathologically all valves appeared grossly enlarged, severely floppy and had extensive myxomatous changes with collagen dissolution. 80 patients had a pre-existing heart murmur first detected at average age 34. Patients remained asymptomatic for an average of 25 years at which time clinical symptoms first appeared. After symptoms developed mitral valve surgery was necessary in most patients within one year. This rapid deterioration could partially be attributed to ruptured chordae in 39 of 76 patients (51%) or atrial fibrillation in 48 of 86 patients (56%). 28 patients had one or more serial clinical evaluations including auscultation, chest x-ray, echocardiography, and cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)     

Results of valve reconstruction for mitral regurgitation secondary to mitral valve prolapse

Mitral valve prolapse (MVP), often the result of myxomatous degeneration of the mitral valve, is the most commonly known pathologic entity leading to pure mitral regurgitation (MR). Reconstruction of the mitral valve rather than replacement is particularly applicable to this pathologic defect, but is not often used in the U.S. Experience with reconstruction of the mitral valve for MR secondary to MVP during the period January 1970 to January 1984 was reviewed. A total of 479 patients with mitral valve disease underwent operation during this period, 82 (17%) of whom had MR secondary to MVP. Thirty-one patients (6%) had valve reconstruction by a technique of leaflet plication and posteromedial anuloplasty. Eleven of these patients had associated cardiac disease requiring correction: 2 requiring aortic valve replacement and 9 requiring coronary artery bypass grafting procedures. One hospital death (3%) and 6 late deaths (19%) occurred, of which only 3 were related to cardiac factors. Major complications included recurrent MR in 5 patients and cerebral embolus in 1 patient. The adjusted 5-year survival rate was 89 +/- 6 (mean +/- standard error of the mean), and the overall survival rate of patients free of cardiac-related complications was 73 +/- 9%. Thus, reconstruction of the mitral valve is a highly effective surgical approach to the management of symptomatic patients with MR secondary to MVP, and its use is favored over replacement in the management of these patients.     

Pitfalls of mitral regurgitation assessment in the presence of mitral valve prolapse

Adequate grading of mitral regurgitation (MR) in patients with mitral valve prolapse (MVP) in the presence of mid-late systolic jets can represent a major challenge. In this entity, jets are commonly overestimated by echocardiography. Correct quantification is crucial and highly relevant for the further management and prognosis of these oftentimes young patients. This case points out potential pitfalls and underlines the importance to systematically include qualitative, quantitative, and semi-quantitative parameters into the echocardiographic assessment.     

Evidence for progression from mild to severe mitral regurgitation in mitral valve prolapse

Little information is available concerning the progression of mild to severe mitral regurgitation (MR) in patients with mitral valve prolapse (MVP). This study reports 86 patients, average age 60 years, who presented with cardiac symptoms, precordial systolic murmur, severe MR and a high incidence of MVP on echocardiography (57 of 75 [75%] ) and left ventriculography (61 of 84 [73%] ). Seventy-five surgically excised mitral valves appeared grossly enlarged and floppy. Histologic studies showed extensive myxomatous changes throughout the leaflets and chordae. Eighty patients had had precordial murmurs first described at average age 34 years, but the average age at which symptoms of cardiac dysfunction appeared was 59. However, once symptoms developed, mitral valve surgery was required within 1 year in 67 of 76 patients who had undergone surgery. Atrial fibrillation, present in 48 of 86 patients (56%), or ruptured chordae tendineae, present in 39 of 76 patients (51%), may have contributed to this rapid progression and deterioration. Additionally, 13 patients had a remote history of documented infective endocarditis. Twenty-eight patients had at least 1 type of serial clinical evaluation that indicated progressive MR in all 28 patients on the basis of changing auscultatory findings (24 of 26), progressive radiographic cardiomegaly (24 of 25), echocardiographic left atrial enlargement (4.3 to 5 cm in 11 patients) and angiographically worsening MR (14 of 15). Twenty-four of these patients had evidence of MVP on at least 1 of their initial studies. Thus, mild MR due to MVP and myxomatous mitral valves is a progressive disease in some patients with MVP.     

Transient mitral regurgitation due to mitral valve prolapse accompanied by systolic anterior motion of the mitral valve

A grade 4/6 systolic murmur, systolic anterior motion of the mitral valve (SAM), and severe mitral regurgitation (MR) documented by two-dimensional Doppler echocardiography developed suddenly on the structurally normal heart of a patient with idiopathic portal hypertension. The patient did not have signs of congestive heart failure and the aforementioned phenomenon disappeared completely when the patient was in hepatic failure. This could be explained by a change in circulating blood volume either by gastrointestinal hemorrhage or hepatic failure.     

Live/real-time three-dimensional transthoracic assessment of mitral regurgitation and mitral valve prolapse

Evaluation of the mitral valve requires appreciation of its complex geometry. To accurately guide surgical interventions and describe pathology, three-dimensional transthoracic echocardiography (TTE) is an immense improvement over the cumbersome mental reconstruction required by two-dimensional approaches. Here we describe real-time, three-dimensional transthoracic techniques for assessing mitral regurgitation and mitral valve prolapse.     

Tricuspid regurgitation in mitral valve prolapse studied by two-dimensional color flow mapping

To assess the incidence of tricuspid regurgitation (TR) in mitral valve prolapse (MVP), 96 patients with MVP and 23 normal control subjects were studied. Subjects in the MVP group were further classified as a group with mitral regurgitation (MR(+) group: 61 cases), and MR(-) group (35 cases). The presence of TR in each group was studied by two-dimensional color flow mapping using a Toshiba SSH-65A apparatus. The incidence of TR was 49% in the MR(+) group and 34% in the MR(-) group, and both (35 cases). The presence of TR in each group was studied by two-dimensional color flow mapping using a Toshiba SSH-65A apparatus. The incidence of TR was 49% in the MR(+) group and 34% in the MR(-) group, and both values were statistically greater than 9% in the control group (p less than 0.001 and p less than 0.05, respectively). A female preponderance was observed only in the MR(+) group. Tricuspid valve prolapse was observed in six cases (10%) in the MR(+) group, two cases (6%) in the MR(-) group, and none in the control group. The mean tricuspid ring dimension did not differ significantly among the three groups. The female patients in MR(+) group had statistically greater measurements than the normal female subjects (p less than 0.01). In conclusion, the incidence of TR was statistically greater in female patients in the MR(+) group than in females in the other groups. It is suspected that functional or pathological changes which induce MVP are likely to progress to the tricuspid ring in female patients.     

Mitral regurgitation in mitral valve prolapse: its mechanisms and time course

To clarify the mechanisms and time course of mitral regurgitation (MR) in mitral valve prolapse (MVP), the relationship between the timing of MR flow patterns on pulsed Doppler echocardiography and phase of mitral valve prolapse on two-dimensional echocardiography was investigated. 1. Thirty-seven patients with MVP were followed by pulsed Doppler echocardiography for one to six years with an average of 2.5 years. At the initial examination, the patients were classified in five subsets on the basis of the presence or timing of MR: 10 without MR, five with early systolic MR, one with mid-systolic MR, 15 with late systolic MR and six with pansystolic MR. During the follow-up period, the timing of MR did not change in 21 patients (three with no MR, five with early systolic MR, seven with late systolic MR and six with pansystolic MR). Various changes were observed in 16 patients, i.e., developments of late systolic MR from no MR in four, of pansystolic from no MR in three, from late systolic MR in five and from mid-systolic MR in one, and disappearing late systolic MR in three. 2. Mitral annular diameter and the prolapsing phase of 118 patients with MVP (44 without MR, eight with early systolic MR, 30 with late systolic MR and 36 with pansystolic MR) were examined by long-axis two-dimensional echocardiography. The mitral annular diameter in patients with early systolic MR was significantly less than that of other MR groups, and the diameter in patients with pansystolic MR was markedly increased. The timing of MR was determined according to the prolapsing phase and the grade of the prolapse and the systolic size of the mitral annulus. Six of the eight patients with early systolic MR first had early systolic prolapse of either mitral leaflet, and then the regurgitant gap of the mitral valve orifice was plugged by the prolapsing leaflet and/or the narrowed mitral annulus during mid-to-late systole. In 18 of the 30 patients with late systolic MR, the grade of prolapse of the mitral valve during mid-to-late systole was more severe, compared with that of early systole. The results of the present study indicated that the occurrence of MR in MVP is various in timing (early, mid-, late or pansystole) and shows various changes the during follow-up study, and that pulsed Doppler echocardiography allows phase analysis of MR in MVP.     

Strain patterns in primary mitral regurgitation due to rheumatic heart disease and mitral valve prolapse

ObjectiveLeft atrial (LA) and left ventricular (LV) remodelling are the adaptive changes that occur in primary mitral regurgitation (MR) and are related to its clinical outcomes. Despite the pathophysiological differences in MR in rheumatic heart disease (RHD) and mitral valve prolapse (MVP), whether the pattern of LV and LA remodelling is different between the two conditions remains unknown. Hence, we compared the LA and LV strain pattern in MR due to RHD, the predominant etiology in developing countries topatients with MVP and age and sex-matched controls.MethodsA total of 50 patients of severe MR which included 30 MVP MR and 20 RHD MR were assessed by strain imaging by speckle tracking echocardiography (STE) and were compared with age and sex-matched controls. 2D STE was used for LA and 3D STE was used for LV strain analysis. LA and LV strain parameters were compared between MVP MR and RHD MR groups.Results30 patients with MVP and 20 with RHD were studied. 60% (n = 30) were symptomatic. Mean GLS was ?17.2 ± 4.4% compared to ?20 ± 3.2% among controls and mean LA strain was 17.35 ± 10.3% compared to 51.34 ± 11.5% among controls which were significantly lower (both p < 0.01). No significant difference in LA strain and GLS was found between MVP and RHD subgroups (LA strain 20.45 ± 11.9% and 14.63 ± 8.85%; p = 0.08; GLS - 18.25 ± 4.3% and-16.2 ± 4.6%; p = 0.12). PALS in the RHD group was lower compared to MVP(p = 0.08) which showed a trend towards significance. LV strain parameters showed no significant difference among the MVP and RHD groups.ConclusionLA and LV strain parameters showed no significant difference in MR due to either RHD or MVP. There was a trend towards lower LA strain in RHD which needs validation with large multicentric studies. The current strain parameters from MVP with the prognostic value may be applied to MR of RHD etiology, pending confirmation of our results by other groups.     

The spectrum of mitral regurgitation in idiopathic mitral valve prolapse: a Color Doppler study

To characterize the spectrum of mitral regurgitation in mitral valve prolapse, one hundred patients were studied by color Doppler flow mapping. The findings were correlated with the clinical presentation and with the possible complications. Mitral regurgitation was absent in 46 patients, mild in 26 patients, moderate in 18 patients and severe in 10 patients. The jet orientation was central in 15 patients, antero-medial in 13 patients and postero-lateral in 26 patients. The regurgitation was early systolic in 7 patients, late systolic in 20 patients and holosystolic in 27 patients. A good agreement was observed between the color flow patterns and the presence, timing and radiation of a murmur. Systolic clicks were not predictors of the presence or the severity of regurgitation. The grade of mitral regurgitation was positively correlated with age, left heart enlargement and valvular redundancy. No sex difference was observed. The prevalence of serious arrhythmias or cerebral ischemic events was not significantly increased when a regurgitation was present.     

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.     

Frequency of atrial fibrillation in patients having mitral valve repair or replacement for pure mitral regurgitation secondary to mitral valve prolapse

Relatively little attention has been paid to the frequency of atrial fibrillation (AF) in patients with mitral regurgitation (MR) secondary to mitral valve prolapse (MVP). We reviewed clinical, electrocardiographic, echocardiographic, hemodynamic, and angiographic findings in 246 patients aged 21 to 84 years (mean 61) (66% men) who had mitral valve repair or replacement for MR secondary to MVP. Immediately before the mitral operation by electrocardiogram, only 37 patients (15%) had AF and the other 209 patients were in sinus rhythm. Of the latter, 32 had had a history of AF that had reverted to sinus rhythm spontaneously or with antiarrhythmic therapy. Thus, a total of 69 patients (28%) had AF at some time. In conclusion, the frequency of AF in patients with MR secondary to MVP and sick enough to warrant a mitral valve operation have a relatively low frequency of AF (persistent in 15%, paroxysmal in another 13%), percentages considerably lower than that seen in patients with mitral stenosis just before a mitral commissurotomy or replacement.