Mitral valve dimensions and motion in Marfan patients with and without mitral valve prolapse. Comparison to primary mitral valve prolapse and normal subjects

To determine mitral valve and extravalvular findings associated with mitral valve prolapse (MVP) in patients with the Marfan syndrome, we compared mitral leaflet and anular dimensions and motion by computerized two-dimensional echocardiography in 53 Marfan patients (28 with M-mode echocardiographic MVP) to those in 48 adults with primary MVP and in 35 normal subjects. Mitral leaflet billowing occurred in 28 of 28 Marfan patients with M-mode MVP versus 24 of 48 with primary MVP (p less than 0.00005), 0 of 25 Marfan patients without M-mode MVP, and 0 of 35 normal subjects (both, p less than 0.0001). Billowing occurred on the first systolic frame in 8 of 28 Marfan-MVP patients, in whom posterior leaflet chordae arose abnormally from the posterior ventricular wall, and in no other subjects. These patients had large mitral valves and normal anular dynamics, whereas the remaining 20 Marfan-MVP patients had increased systolic anular expansion. Marfan-MVP patients were younger than those without MVP (29 +/- 12 vs. 38 +/- 15 years, p less than 0.02) and had lower body mass index (19.8 +/- 2.7 vs. 23.9 +/- 2.9 kg/m2, p less than 0.00005) and systolic blood pressure (120 +/- 20 vs. 133 +/- 20 mm Hg, p less than 0.05), similar to differences between primary MVP and normal subjects in body mass index (21.5 +/- 3.0 vs. 23.9 +/- 4.8 kg/m2, p less than 0.01) and systolic pressure (118 +/- 14 vs. 125 +/- 18 mm Hg, p less than 0.05). Marfan patients with and without MVP had similar arm span, arm span to height ratio, upper to lower segment ratio, and prevalence of ectopia lentis and thoracic bony abnormalities, but arachnodactyly was more frequent in those with MVP (82% and 48%, respectively; p less than 0.02). We conclude that 1) leaflet billowing occurs more uniformly in Marfan patients with MVP than in primary MVP, 2) MVP in Marfan patients may be due to either valve enlargement with distinctively abnormal chordal architecture or abnormal mitral anular distensibility, 3) Marfan patients with MVP have low body weight and systolic blood pressure, similar to primary MVP, and 4) Marfan patients with MVP more commonly have arachnodactyly but otherwise have similar skeletal and anthropometric characteristics to other Marfan patients.     

Relationship between auscultatory events and structural abnormalities in mitral valve prolapse: a two-dimensional echocardiographic evaluation

The purpose of this study was to examine the relationship between the valvular abnormalities and auscultatory findings of patients with mitral valve prolapse (MVP). Forty patients with typical auscultatory and two-dimensional echocardiographic (2DE) findings were studied. Eleven of 14 patients with anterior leaflet MVP (group I) had mid to late systolic clicks without murmurs of mitral regurgitation, while eight of nine patients with posterior leaflet prolapse (group II) and 13 of 17 patients with combined anterior and posterior prolapse (group III) had murmurs of mitral regurgitation. In each subgroup the mitral anulus size was greater than a control group (group I = 3.8 +/- 0.1 cm, p less than 0.025; group II = 3.9 +/- 0.1 cm, p less than 0.005; group III = 4.2 +/- 0.2 cm, p less than 0.001; and control = 3.4 +/- 0.1 cm), but the largest anulus was present in patients with combined prolapse. As demonstrated by 2DE, prolapse of a single mitral leaflet may occur in many instances of MVP. Murmurs of mitral regurgitation occur frequently when the posterior mitral leaflet alone prolapses, while isolated clicks are found with anterior mitral leaflet prolapse.     

QT dispersion in patients with mitral valve prolapse is related to the echocardiographic degree of the prolapse and mitral leaflet thickness.

BACKGROUND: Ventricular arrhythmias are common in patients with mitral valve prolapse (MVP). Previous studies have provided evidence that a higher degree of systolic mitral valve displacement and the presence of a thickened anterior mitral leaflet are related to an increased incidence of complex ventricular arrhythmias and risk of sudden death in these patients. The aim of our study was to investigate whether QT dispersion in patients with MVP is associated with the echocardiographic degree of the prolapse and mitral leaflet thickness. METHODS: QT and JT intervals and dispersions were measured in 89 patients with primary mitral valve prolapse (26 men and 63 women with mean age 39 +/- 14 years). All patients underwent a full echocardiographic examination and a scoring system was used to determine the degree of MVP. Anterior mitral leaflet thickness was also measured. Twenty-four hour Holter monitoring was used to assess ventricular arrhythmogenesis. RESULTS: According to their echocardiographic score. patients were divided into three groups (Group A. B and C) reflecting the different degrees of the prolapse. QT dispersion in patients with the highest degree of MVP, i.e. Group C was significantly greater (65 +/- 13 ms) than that of the other two groups (Group A: 38 +/- 14 ms, P<0.005 and Group B: 45 +/- 12 ms, P<0.005). Similar differences between groups were also found for JT dispersion. Multiple regression analysis revealed that among the demographic and clinical variables that were tested, only the echocardiographic degree of the prolapse and anterior mitral leaflet thickness were independently associated with QT dispersion. Holter monitoring showed that the incidence of complex ventricular arrhythmias was also higher in patients with more severe MVP. CONCLUSIONS: Our results indicate that QT and JT dispersions are related to the echocardiographic degree of MVP and mitral leaflet thickness. The echocardiographic assessment of the severity of the prolapse may help to identify a subgroup of patients at increased risk of life-threatening arrhythmias.     

Identification of the increased frequency of cardiovascular abnormalities associated with mitral valve prolapse by two-dimensional echocardiography

Two-dimensional echocardiography (2-D echo) was performed in 86 consecutive patients with mitral valve prolapse (MVP) and in 25 normal subjects. In normal subjects, mitral leaflet thickness was 3.5 +/- 0.8 mm (mean +/- standard deviation) and the mitral leaflet thickness to aortic wall thickness ratio was 1.0 +/- 0.2. Patients with MVP were separated into 2 groups: those with normal mitral thickness (less than or equal to mean + 2 SD observed in normal subjects, i.e., less than or equal to 5.1 mm) and normal mitral thickness to aortic wall thickness ratio (less than or equal to mean + 2 SD observed in normal subjects, i.e., less than or equal to 1.4) (group I) and others in whom these values were increased (group II). In group I, mitral thickness was 3.6 +/- 0.6 mm and mitral thickness to aortic wall thickness ratio was 1.1 +/- 0.1, and in group II, mitral thickness was 8.8 +/- 1.2 mm and mitral thickness to aortic wall thickness ratio was 2.2 +/- 0.5. The only significant cardiovascular abnormalities in group I were mitral regurgitation in 2 patients and tricuspid valve prolapse in 1 patient. In group II, 7 patients had clinically significant mitral regurgitation, 8 had aortic root abnormalities, 4 had tricuspid valve prolapse and 6 had Marfan's syndrome. Cardiovascular abnormalities were present in 60% (18 of 30) of patients in group II and in 6% (3 of 56) of patients in group I (p less than 0.001). Two-dimensional echo enabled the identification of a subset of patients with MVP who had thickened mitral leaflets. These patients had an increased incidence of cardiovascular abnormalities.     

Relation of echocardiographic morphology of the mitral apparatus to mitral regurgitation in mitral valve prolapse: assessment by Doppler color flow imaging

Few data exist regarding the relationship of valvular anatomy and coaptation to the presence of mitral regurgitation (MR) in patients with mitral valve prolapse (MVP). Therefore this study was undertaken to assess the ability of two-dimensional echocardiographic features of mitral valve morphology to predict the presence, direction, and magnitude of MR as assessed by color Doppler flow imaging. MR was present in 21 of 46 patients with MVP on two-dimensional echocardiography. Echocardiograms were specifically evaluated for leaflet apposition, leaflet morphology, and mitral anulus diameter. Color flow images were analyzed for presence of MR, direction of the regurgitant jet, and area encompassing the largest jet visible in any view. Abnormal mitral leaflet coaptation on two-dimensional echocardiography was strongly associated with the presence of MR (p = 0.003), being present in 15 of 21 patients with as compared with 5 of 25 patients without MR. Similarly, mitral leaflet thickness and MR were closely associated (p = 0.0035), with the latter being present in 9 of 30 patients with normal and 12 of 16 patients with excessive leaflet thickness. MR jet direction tended to be anterior to central with posterior leaflet prolapse and posterior or central with anterior leaflet prolapse (p = 0.02). Maximal jet area of MR tended to be larger in patients with compared with those without mitral annular dilatation (5.4 +/- 2.3 versus 2.1 +/- 1.9 cm2, p = 0.001), and in those with abnormal rather than normal leaflet thickness (4.5 +/- 2.7 versus 2.0 +/- 1.6 cm2, p = 0.009). Thus the presence, direction, and size of MR jets in MVP are related to structural abnormality of the mitral apparatus on echocardiography.     

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.     

The importance of secondary mitral valve involvement in primary aortic valve endocarditis; the mitral kissing vegetation.

AIMS: Secondary involvement of the mitral valve is well documented in primary aortic valve endocarditis. A poorly considered, but probably important causative mechanism, involving both left-sided valves, is 'mitral kissing vegetation'. This results from large aortic vegetations prolapsing into the left ventricular outflow tract and making contact with the ventricular aspect of the anterior mitral leaflet thus causing secondary infection. METHODS AND RESULTS: In 192 consecutive patients with aortic valve endocarditis, two to 18 (7.6+/-2.6) serial transoesophageal echocardiographic examinations were analysed per patient to demonstrate the development of mitral kissing vegetation on initially competent, morphologically normal mitral leaflets. In 19 patients (9.9%) with aortic valve endocarditis, mitral kissing vegetation was diagnosed within 11.6+/-9.0 (range 1-31) days following primary transoesophageal echocardiography. In all patients with mitral kissing vegetation, vegetations attached to aortic cusps were >6 mm. On hospital admission, patients with aortic valve endocarditis plus mitral kissing vegetation presented more often with a positive sepsis score, embolic events, renal failure and had larger aortic valve vegetations (9.9+/-3.3 vs 5.7+/-2.3 mm). Prognosis of aortic valve endocarditis plus mitral kissing vegetation was unfavourable (P<0.005) when compared to patients with aortic valve endocarditis alone. CONCLUSION: In aortic valve endocarditis early echocardiographic detection of mitral kissing vegetation and timely surgery may preserve the mitral valve apparatus, and favourably influence the long-term prognosis.     

An unusual pulsed-wave tissue Doppler pattern in mitral valve prolapse: spikes on systolic velocities

BACKGROUND: Mitral valve prolapse (MVP) can be associated with wall-motion abnormalities. Pulsed-wave Doppler tissue imaging (DTI) has been proposed as a method to obtain myocardial velocities with a high spatial and temporal resolution. Our aim was to investigate whether a specific DTI pattern exists in myocardial segments of patients with MVP. METHODS AND RESULTS: We studied 49 consecutive patients with clinically suspected MVP. MVP was diagnosed in 35 patients. After recording the conventional echocardiographic variables, apical-directed left ventricular (LV) segmental myocardial velocities were obtained by DTI. The DTI analysis of myocardial segments revealed a distinct spectral Doppler pattern of mid- and basal posterior and lateral walls consistent with spikes on systolic velocities. These spikes were noticed in 23 (65%) patients with MVP but in none of the 14 subjects without MVP (P = 0.002). The MVP patients with spikes had larger mitral annulus diameters and higher amounts of maximal leaflet displacement when compared with those without spikes (34.8 +/- 5 mm vs 31.2 +/- 4 mm, P = 0.03 and 4.1 +/- 1 ms vs 3.1 +/- 1 mm, P = 0.01, respectively). CONCLUSION: This newly described unique DTI pattern, which may be observed in the majority of patients with MVP, may contribute to the diagnosis of disease. However, future studies are required to evaluate the clinical significance and pathophysiology of the spikes on systolic velocities of posterior and lateral walls in patients with MVP.     

Abnormal chordal insertion: a cause of mitral valve prolapse

Although the morphology of mitral valve prolapse (MVP) has been described, abnormalities of chordal arrangement and insertion have not been emphasized. We retrospectively reviewed 23 surgically-excised MVP and 10 control mitral valves removed at necropsy. Two-dimensional echocardiograms (2DE) were available in 10 MVP and in six additional controls. 2DE accurately assessed the length of anterior leaflet (AL) and posterior leaflet (PL) of the mitral valve (3.2 +/- 0.7 cm and 2.2 +/- 0.6 cm, respectively) as compared to morphologic measurements (3.0 +/- 0.4 cm and 2.1 +/- 0.4 cm, respectively). However, annular diameter as assessed by echocardiography was significantly less (4.6 +/- 0.7 cm) than that derived by morphologic measurements of annular circumference (AC) (5.3 +/- 0.7 cm). The AL and PL lengths and the mitral anuli were significantly larger in patients with MVP as compared to controls (p less than 0.01) when assessed both by 2DE and by morphology. The ratio of the maximum distance of chordal separation/AC was 0.11 +/- 0.04 in MVP and 0.13 +/- 0.02 in controls (p less than 0.05). Chordal divisions were increased in MVP (4.2) compared to controls (3.1, p less than 0.01). The most striking morphologic feature of MVP was abnormal chordal insertion and a random, unpredictable pattern of chordal distribution. We postulate that abnormal chordal architecture may be responsible for unequal stress on the valve leaflets and may thus lead to MVP.     

Long-term site-related differences in the progression and regression of the idiopathic mitral valve prolapse syndrome.

The natural history of uncomplicated mitral valve prolapse (MVP) is not clearly understood. To determine the site-related differences in regression and progression of MVP, 112 patients with idiopathic MVP were enrolled in this echocardiographic follow-up study. Cardiovascular complications, including dysarrhythmias (n = 3, 2.7%), overt congestive heart failure (n = 4, 3.6%), progression of mitral regurgitation over one grade (n = 28, 25.0%), newly confirmed chordal rupture (n = 1, 0.9%), and surgical repair (n = 2, 1.8%), were observed in these patients during a follow-up period of 1-13 years (mean, 4.0 +/- 2.8 years). Multivariate analysis and Kaplan-Meier analysis revealed that posterior leaflet prolapse and significant mitral regurgitation (grade >/=2) were considerable risks for cardiovascular complications. Regression of MVP was seen in 17 (18.7%) of the anterior prolapse patients; however, new prolapse was observed in 40 (35.7%) patients, mainly in posterior prolapse patients. These results suggest that site-related differences exist in uncomplicated MVP prognosis and that MVP in the posterior leaflet has a poor outcome compared to that in the anterior leaflet.     

Comparison of cardiac findings in patients with mitral valve prolapse who die suddenly to those who have congestive heart failure from mitral regurgitation and to those with fatal noncardiac conditions.

Sudden death occurs in a small but important subset of patients with mitral valve prolapse (MVP). Clinical criteria for identifying patients at risk for sudden death have been elusive. To determine if certain morphologic characteristics were present in hearts from patients with sudden cardiac death and MVP, autopsy hearts from persons with sudden death and isolated MVP who were previously asymptomatic or had a history of cardiac arrhythmias (n = 27) were compared with (1) hearts from patients with congestive heart failure (CHF) and mitral regurgitation (MR) secondary to MVP (n = 14), and (2) hearts from persons dying from non-cardiac causes in which MVP was an incidental finding (n = 19). Patients who died suddenly were younger than both patients with MR/CHF and incidental cases (37 +/- 10 vs 65 +/- 16 and 58 +/- 21 years, respectively, p less than 0.001). Mitral valve annular circumference, anterior and posterior mitral valve leaflet lengths, posterior mitral valve thickness, and presence and extent of endocardial plaque were greater in hearts from patients with sudden death than hearts from those with incidental MVP. Hearts from patients with MR/CHF weighed significantly more, had greater left and right atrial cavity sizes and left ventricular cavity diameter than hearts from both sudden death and incidental cases.     

Cyclic variation of thickness in an age-related thick mitral valve observed by transthoracic echocardiography.

The cyclic variation of thickness during the cardiac cycle in age-related degenerative mitral valve (MV) has not been reported. Transthoracic echocardiography was used to evaluate the cyclic alteration in MV thickness in 40 patients with age-related MV thickening (diastolic MV thickness > or = 4 mm, age 70 +/- 14 years), 10 with mitral valve prolapse (MVP, age 49 +/- 11 years), 10 with rheumatic mitral stenosis (MS, age 66 +/- 9 years), and 31 control subjects (diastolic MV thickness < or = 3.6 mm, 53 +/- 17 years). After determination of the site of maximal thickness during diastole, the maximal and minimal thickness during systole of the anterior MV were measured. The percent change in MV thickness from diastole to systole (%deltaT) was calculated. The mitral regurgitation (MR) area was measured on color Doppler echocardiogram. The %deltaT (mean +/- sd) in age-related thickened MV and MVP groups were similar and significantly greater than that in control (60 +/- 8%, 61 +/- 6% vs 32 +/- 9%, p < 0.001). MR area was significantly greater in the age-related thickened MV group than that in controls (160 +/- 205 mm2 vs 14 +/- 40 mm2, p < 0.05). The %deltaT in MS (10 +/- 6%) was smallest (p < 0.001). A large cyclic alteration in valvular thickness was observed in the age-related degeneration of the MV and may be the cause of large MR despite no leaflet prolapse. The echocardiographic assessment of cyclic variation of MV thickness is feasible for estimating the histologic damage in thick MV.     

Utility of the posterior to anterior mitral valve leaflets length ratio in prediction of outcome of percutaneous balloon mitral valvuloplasty

Background: Scoring of mitral stenosis (MS) severity is very important for selection of patients for balloon mitral valvuloplasty (BMV). Objective: We propose a novel yet simple, independent parameter of MS severity based on the posterior mitral valve leaflet to anterior mitral valve leaflet length ratio (PMVL/AMVL length ratio). It could be a useful predictor to outcome of BMV. Subjects and methods: A total of 106 patients (mean age 29.1 ± 8.6 years) had MS with mitral valve score of eight or less. The length of anterior mitral valve leaflet and posterior mitral valve leaflet were measured. Patients were classified into group with ratio ≥ 1/2 and group of ratio <1/2. Eighty‐five healthy control subjects were studied. Results: Patients with PMVL/AMVL ratio ≥ 1/2 post‐BMV had lower transmitral gradients (4.5 ± 3.1 mmHg vs. 9.7 ± 2.1 mmHg, P < 0.002) and greater mitral valve area (MVA) (2.09 ± 0.3 cm² vs. 1.5 ± 0.2 cm², P < 0.001), lower pulmonary artery systolic pressure (PASP) (23.8 ± 14.3 mmHg vs. 34.2 ± 12.5 mmHg, P < 0.001), left atrial pressure (10.2 ± 6.7 mmHg vs. 18.9 ± 6.4 mmHg, P < 0.001), and lower incidence of de novo or worsening of mild mitral regurgitation (MR; 1.64% vs. 8.9%, 0% vs. 6.6%, P < 0.001). PMVL/AMVL length ratio was positively correlated with post‐BMV MVA (r = 0.69, P < 0.002), PASP (r = 0.592, P < 0.003), and negatively correlated with incidence of de novo or worsening of mild MR (r =–0.78, –0.93, P < 0.001). The regression analyses revealed that PMVL/AMVL ratio is the best and a reliable predictor of success and outcome of BMV, hazard ratio (95% confidence interval) 0.12 (0.05–52), P < 0.001. Conclusion: Length ratio of PMVL/AMVL assessment with echocardiography is an excellent simple predictor of post‐BMV mitral valve area and the cardiac events. (Echocardiography 2011;28:1068‐1073)     

Normal joint mobility in mitral valve prolapse

Thirty-seven adults (19 male, 18 female) with mitral valve prolapse (MVP) were examined for evidence of joint hypermobility scored on a 0-9 scale. None of the patients had hypermobility scores exceeding 3, and comparison with 37 healthy age and sex matched controls recruited from hospital staff failed to show an increased prevalence of hypermobility in MVP. There was no evidence that the MVP syndrome is a forme fruste of a heritable disorder of connective tissue.     

Clinical utility of new real time three-dimensional transthoracic echocardiography in assessment of mitral valve prolapse

BACKGROUND: Noninvasive and accurate assessment of mitral valve anatomy has become integral in the presurgical evaluation of patients with mitral valve prolapse (MVP). Recently developed real time three-dimensional (RT3D) ultrasound allows online acquisition, rendering, and can provide accurate information on cardiac structures. We sought to evaluate the feasibility of RT3D for the assessment of MVP segments when compared with transesophageal echocardiography (TEE) and intraoperative findings. METHODS: We examined 42 patients with MVP using RT3D, two-dimensional (2D) transthoracic echocardiography (TTE) and TEE. For RT3D analysis, cropping planes were used to slice the 3D volume on line to visualize the prolapsed segments of the mitral valve leaflets. The mitral valve was divided into six segments based on the American Society of Echocardiography's recommendations. Two experienced cardiologists evaluated echocardiographic images. RESULTS: Adequate RT3D images of the mitral valve were acquired in 40 out of 42 patients. The sensitivity and specificity of RT3D for defining prolapsed segments when compared with TEE were 95% and 99%, respectively (anterior leaflet: 96% and 99%, posterior leaflets: 93% and 100%, respectively). The sensitivity and specificity of TTE were 93% and 97%, respectively (anterior leaflet: 96% and 98%, posterior leaflets: 90% and 97%, respectively). Interobserver agreement for RT3D (Kappa 0.95, 95% confidence interval [CI] 0.91-1.00) was significantly greater than for TTE (Kappa 0.85, 95% CI 0.78-0.93) (P < 0.05). The elapsed time for completion of RT3D (14.4 +/- 2.8 min) was shorter than for TEE (26.4 +/- 4.7 min, P < 0.0001) and TTE (19.0 +/- 3.1 min, P< 0.0001). CONCLUSIONS: RT3D is fast, accurate, and highly reproducible for assessing MVP.     

Heart rate turbulence and heart rate variability in patients with mitral valve prolapse.

AIMS: Heart rate turbulence (HRT) and heart rate variability (HRV) have been shown to be independent and powerful predictors of mortality in a specific group of cardiac patients. However, the predictive values of HRV alone is modest and information on HRV in patients with mitral valve prolapse (MVP) has so far been conflicting. In addition, no studies have previously evaluated HRT in patients with MVP. To define better the effects of MVP on cardiac autonomic function, we assessed HRT and time-domain parameters of HRV in patients with MVP. METHODS AND RESULTS: Fifty patients with MVP and 70 controls without MVP were investigated. The diagnosis of MVP was confirmed by cross-sectional echocardiography in the parasternal long-axis view and apical 4-chamber view. The HRV and turbulence analysis were assessed from a 24-hour Holter recording. When HRT parameters were compared, the values of the HRT onset and slope were significantly lower in MVP patients than in the controls group (-0.109+/-0.207 vs. -0.289+/-0.170%, P=0.001 and 8.6+/-7.2 vs. 11.5+/-7.4 ms/RRI, P=0.043, respectively) and the number of patients who had abnormal HRT onset was significantly higher in the MVP group than in controls (15 vs. 8, P=0.011). In addition, HRV parameters were not statistically different between the two groups. CONCLUSION: Although we found that the decrease in HRV parameters was not significantly different between MVP patients and controls, HRT variables (especially HRT onset) were significantly lower in MVP patients. Therefore, in our opinion, HRT is an attractive, easily applicable, and better way of non-invasive risk prediction compared with another non-invasive risk predictor, HRV.     

Mitral valve dimensions and motion and familial transmission of mitral valve prolapse with and without mitral leaflet billowing

To test the hypothesis that mitral valve prolapse may be due either to billowing of mitral leaflets into the left atrium or to dynamic expansion of the mitral anulus, mitral leaflet and annular dimensions and motion were measured by computer-assisted two-dimensional echocardiography in 35 normal adults and 48 subjects with auscultatory and M-mode echocardiographic evidence of mitral prolapse. Among normal subjects, mitral leaflet and annular dimensions tended to be larger compared with body size or left ventricular size in women than in men. Mitral leaflet billowing was observed in 24 (50%) of 48 patients with mitral prolapse and 0 of 35 normal subjects (100% specificity). The 24 patients without leaflet billowing had greater systolic expansion of the mitral anulus (p less than 0.0001) than did normal adults or patients with leaflet billowing (41 +/- 14% versus 27 +/- 12% and 22 +/- 11%, respectively) and a significantly lower body mass index (p less than 0.005 versus normal group). The ratio of anterior plus posterior mitral leaflet length to end-systolic annular diameter was lower in patients with prolapse without leaflet billowing than in normal subjects (1.09 +/- 0.12 versus 1.19 +/- 0.15, respectively, p less than 0.01) or patients with leaflet billowing (1.21 +/- 0.17, p less than 0.05). Among 35 relatives with mitral prolapse in the families of 23 patients with prolapse, the pattern was the same as in the proband in 31 (89%) (p less than 0.000002).(ABSTRACT TRUNCATED AT 250 WORDS)     

Tissue Doppler echocardiography reveals insufficient contractile reserve recruitment during effort in subjects with mitral valve prolapse and those with thick mitral valve

OBJECTIVE: To assess by tissue Doppler echocardiography (TDE), the tissue velocities, both at rest and after exercise stress testing, in subjects with mitral valve prolapse (MVP) and those with thick mitral valve (TMV). METHODS: Twenty individuals with typical MVP, 30 with TMV, and 30 healthy controls were enrolled. TDE was performed at the basal-inferior wall and the parameters evaluated were the S, Em, and Am velocities, as well as the Em/Am ratio. RESULTS: The mean S-wave at rest was higher in subjects with MVP compared to that of the TMV (P < 0.01) and the control groups (P = 0.00005), whereas after exercise it was higher in the control group compared to either MVP (P = 0.013) or TMV group (P = 0.00002). The mean Em wave at rest was higher in the control individuals both at rest (P = 0.007 compared with MVP group and P = 0.013 compared with TMV group), and after exercise (P = 0.0002 and 0.0009, respectively). The Am wave in the MVP group was higher compared with TMV and control subjects at rest (P = 0.022 and 0.00001, respectively) but it was not after exercise (P = ns for both comparisons). The Em/Am ratio of the control group at rest was higher than that of the MVP (P = 0.0000) and TMV (P = 0.00028) groups. However, after exercise, it was higher only when compared with the MVP group (P = 0.016). CONCLUSIONS: Subjects with MVP and those with TMV exhibit a less effective contractile response to exercise compared to healthy individuals. Some degree of diastolic dysfunction, particularly after exercise, was also detected in the individuals with MVP.     

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.     

Usefulness of three-dimensional echocardiography for the evaluation of mitral valve prolapse: an intraoperative study

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the feasibility of intraoperative three-dimensional (3D) transesophageal echocardiography (TEE) in patients referred for mitral valve prolapse (MVP) repair and to compare two-dimensional (2D) TEE and 3D TEE and surgical findings. METHODS: Forty-six patients (mean age 67 +/- 11 years) underwent 3D TEE intraoperatively. Measurements were made of the posterior part of mitral annulus circumference (PMAC), and the width of mitral valve surgical resection on the mitral annulus (WMVR). Using 3D TEE, MVP topography was described, and PMAC in diastole and the width of implantation of MVP on the mitral annulus (WMVP) in systole were measured. RESULTS: 3D TEE was successful in 42 patients (91%). 2D and 3DTEE correctly predicted MVP localization in 38 (90%) and 36 (86%) patients, respectively (p = NS). 3D TEE and surgical PMAC were 89 +/- 13 and 93 +/- 21 mm, respectively (p = 0.01, R = 0.42). WMVR and WMVP were 28 +/- 11 mm and 26 +/- 11 mm, respectively (p <0.0001, R = 0.82). WMVR/anatomic PMAC (0.29 +/- 0.11) and WMVP/3D echo PMAC (0.32 +/- 0.11) were correlated (p <0.0001, R= 0.69). CONCLUSION: Intraoperative 3D TEE evaluation of MVP is feasible. MVP width and its ratio to the mitral annulus were assessed, and found to correlate with surgical findings. These 3D data may be of value to the surgeon when performing mitral valve repair.