eMedicine Specialties > Cardiology > Valvular Heart Disease

Mitral Valve Prolapse: Differential Diagnoses & Workup

Author: Bhavik V Thakkar, MD, Associate Faculty, Department of Medical Education, Abbott Northwestern Hospital; Consulting Staff, Department of Medicine, Regency Hospital
Coauthor(s): Alan D Forker, MD, Professor of Medicine, Program Director of Cardiovascular Fellowship, MidAmerica Heart Institute, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research Center, MidAmerica Heart Institute of Saint Luke's Hospital; Adam E Schussheim, MD, Consulting Staff, Department of Internal Medicine, Bridgeport Hospital of the Yale-New Haven Medical Center
Contributor Information and Disclosures

Updated: Jul 30, 2008

Differential Diagnoses

Mitral Regurgitation

Other Problems to Be Considered

Consider all inheritable connective tissue disorders mentioned previously, with emphasis on Marfan syndrome because of its increased frequency. All causes of mitral regurgitation should be considered. However, if only a mid-systolic click and/or a mid-to-late systolic murmur is present, the diagnosis is almost always MVP. If only a late systolic murmur without a click is present, papillary muscle dysfunction secondary to coronary artery disease is a possibility.

Workup

Imaging Studies

  • Echocardiography
    • Diagnostic criteria
      • Perloff et al set the stage for accurately diagnosing mitral valve prolapse (MVP) by expanding the diagnostic standards to include clinical and echocardiographic criteria.2,3
      • In a Framingham Heart Study, Freed et al historically described echocardiographic criteria for MVP as classic versus nonclassic (see below).4
      • Use of the parasternal long-axis view reduce the over diagnosis of MVP.1
    • Findings
      • Classic MVP: The parasternal long-axis view shows > 2 mm superior displacement of the mitral leaflets into the left atrium during systole, with a leaflet thickness of at least 5 mm.
      • Nonclassic MVP: Displacement is > 2 mm, with a maximal leaflet thickness of < 5 mm.
      • Other: Other echocardiographic findings that should be considered as criteria are leaflet thickening, redundancy, annular dilatation, and chordal elongation.
  • Contrast ventriculography: This study can also help in defining MVP with or without mitral regurgitation. However, with the advent of echocardiography, contrast ventriculography is rarely necessary.
  • Chest radiography: Radiographs may demonstrate the progression from asymptomatic to chronic, severe mitral regurgitation with the development of cardiomegaly secondary to left atrial and left ventricular dilatation and evidence of heart failure. See Medscape's Heart Failure Resource Center.

More on Mitral Valve Prolapse

Overview: Mitral Valve Prolapse
Differential Diagnoses & Workup: Mitral Valve Prolapse
Treatment & Medication: Mitral Valve Prolapse
Follow-up: Mitral Valve Prolapse
References
[ CLOSE WINDOW ]

References

  1. Levine RA, Triulzi MO, Harrigan P, Weyman AE. The relationship of mitral annular shape to the diagnosis of mitral valve prolapse. Circulation. Apr 1987;75(4):756-67. [Medline].

  2. Perloff JK, Child JS. Mitral valve prolapse. Evolution and refinement of diagnostic techniques. Circulation. Sep 1989;80(3):710-1. [Medline].

  3. Perloff JK, Child JS, Edwards JE. New guidelines for the clinical diagnosis of mitral valve prolapse. Am J Cardiol. May 1 1986;57(13):1124-9. [Medline].

  4. Freed LA, Levy D, Levine RA, et al. Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med. Jul 1 1999;341(1):1-7. [Medline]. [Full Text].

  5. Gilon D, Buonanno FS, Joffe MM, et al. Lack of evidence of an association between mitral-valve prolapse and stroke in young patients. N Engl J Med. Jul 1 1999;341(1):8-13. [Medline].

  6. Alpert MA, Mukerji V, Sabeti M, et al. Mitral valve prolapse, panic disorder, and chest pain. Med Clin North Am. Sep 1991;75(5):1119-33. [Medline].

  7. American College of Cardiology/American Heart Association. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 guidelines for the Manag. J Am Coll Cardiol. 2006;48:1-148:[Medline]. [Full Text].

  8. American College of Cardiology/American Heart Association. ACC/AHA guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association. Task Force on Practice Guidelines (Committee on Management of Patients with Valvular Heart Disease. J Am Coll Cardiol. Nov 1998;32(5):1486-588. [Medline]. [Full Text].

  9. Avierinos JF, Gersh BJ, Melton LJ 3rd, Bailey KR, Shub C, Nishimura RA, et al. Natural history of asymptomatic mitral valve prolapse in the community. Circulation. Sep 10 2002;106(11):1355-61. [Medline].

  10. Barnett HJ, Boughner DR, Taylor DW, Cooper PE, Kostuk WJ, Nichol PM. Further evidence relating mitral-valve prolapse to cerebral ischemic events. N Engl J Med. Jan 17 1980;302(3):139-44. [Medline].

  11. Bryhn M, Persson S. The prevalence of mitral valve prolapse in healthy men and women in Sweden. An echocardiographic study. Acta Med Scand. 1984;215(2):157-60. [Medline].

  12. Ciancamerla F, Paglia I, Catuzzo B, Morello M, Mangiardi L. Sudden death in mitral valve prolapse and severe mitral regurgitation. Is chordal rupture an indication to early surgery?. J Cardiovasc Surg (Torino). Apr 2003;44(2):283-6. [Medline].

  13. Clemens JD, Horwitz RI, Jaffe CC, Feinstein AR, Stanton BF. A controlled evaluation of the risk of bacterial endocarditis in persons with mitral-valve prolapse. N Engl J Med. Sep 23 1982;307(13):776-81. [Medline].

  14. Cohn LH, Couper GS, Aranki SF, Rizzo RJ, Kinchla NM, Collins JJ Jr. Long-term results of mitral valve reconstruction for regurgitation of the myxomatous mitral valve. J Thorac Cardiovasc Surg. Jan 1994;107(1):143-50; discussion 150-1. [Medline].

  15. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. Circulation. Jul 1 1997;96(1):358-66. [Medline].

  16. David TE, Omran A, Armstrong S, Sun Z, Ivanov J. Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg. Jun 1998;115(6):1279-85; discussion 1285-6. [Medline].

  17. Davidsen B, Egeblad H, Pietersen A. Thromboembolism in patients with advanced mitral valve prolapse. J Intern Med. Dec 1989;226(6):433-6. [Medline].

  18. Devereux RB. Recent developments in the diagnosis and management of mitral valve prolapse. Curr Opin Cardiol. Mar 1995;10(2):107-16. [Medline].

  19. Devereux RB, Hawkins I, Kramer-Fox R, Lutas EM, Hammond IW, Spitzer MC. Complications of mitral valve prolapse. Disproportionate occurrence in men and older patients. Am J Med. Nov 1986;81(5):751-8. [Medline].

  20. Devereux RB, Kramer-Fox R, Brown WT, Shear MK, Hartman N, Kligfield P. Relation between clinical features of the mitral prolapse syndrome and echocardiographically documented mitral valve prolapse. J Am Coll Cardiol. Oct 1986;8(4):763-72. [Medline].

  21. Devereux RB, Kramer-Fox R, Shear MK, et al. Diagnosis and classification of severity of mitral valve prolapse: methodologic, biologic, and prognostic considerations. Am Heart J. May 1987;113(5):1265-80. [Medline].

  22. Devlin WH, Starling MR. Outcome of valvular heart disease with vasodilator therapy. Compr Ther. 1994;20(10):569-74. [Medline].

  23. Freed LA, Benjamin EJ, Levy D, et al. Mitral valve prolapse in the general population: the benign nature of echocardiographic features in the Framingham Heart Study. J Am Coll Cardiol. Oct 2 2002;40(7):1298-304. [Medline].

  24. Glesby MJ, Pyeritz RE. Association of mitral valve prolapse and systemic abnormalities of connective tissue. A phenotypic continuum. JAMA. Jul 28 1989;262(4):523-8. [Medline].

  25. Grayburn PA. Vasodilator therapy for chronic aortic and mitral regurgitation. Am J Med Sci. Sep 2000;320(3):202-8. [Medline].

  26. Grigioni F, Enriquez-Sarano M, Ling LH, Bailey KR, Seward JB, Tajik AJ. Sudden death in mitral regurgitation due to flail leaflet. J Am Coll Cardiol. Dec 1999;34(7):2078-85. [Medline].

  27. Kligfield P, Hochreiter C, Kramer H, et al. Complex arrhythmias in mitral regurgitation with and without mitral valve prolapse: contrast to arrhythmias in mitral valve prolapse without mitral regurgitation. Am J Cardiol. Jun 1 1985;55(13 Pt 1):1545-9. [Medline].

  28. Kostuk WJ, Boughner DR, Barnett HJ, Silver MD. Strokes: A complication of mitral-leaflet prolapse?. Lancet. Aug 13 1977;2(8033):313-6. [Medline].

  29. Kramer HM, Kligfield P, Devereux RB, Savage DD, Kramer-Fox R. Arrhythmias in mitral valve prolapse. Effect of selection bias. Arch Intern Med. Dec 1984;144(12):2360-4. [Medline].

  30. Kulan K, Komsuoglu B, Tuncer C, Kulan C. Significance of QT dispersion on ventricular arrhythmias in mitral valve prolapse. Int J Cardiol. Jun 1996;54(3):251-7. [Medline].

  31. Levine RA, Handschumacher MD, Sanfilippo AJ, Hagege AA, Harrigan P, Marshall JE. Three-dimensional echocardiographic reconstruction of the mitral valve, with implications for the diagnosis of mitral valve prolapse. Circulation. Sep 1989;80(3):589-98. [Medline].

  32. Levine RA, Stathogiannis E, Newell JB, et al. Reconsideration of echocardiographic standards for mitral valve prolapse: lack of association between leaflet displacement isolated to the apical four chamber view and independent echocardiographic evidence of abnormality. J Am Coll Cardiol. May 1988;11(5):1010-9. [Medline].

  33. Levine RA, Stathogiannis E, Newell JB, et al. Reconsideration of echocardiographic standards for mitral valve prolapse: lack of association between leaflet displacement isolated to the apical four chamber view and independent echocardiographic evidence of abnormality. J Am Coll Cardiol. May 1988;11(5):1010-9. [Medline].

  34. Levy D, Savage D. Prevalence and clinical features of mitral valve prolapse. Am Heart J. May 1987;113(5):1281-90. [Medline].

  35. Ling LH, Enriquez-Sarano M, Seward JB, Orszulak TA, Schaff HV, Bailey KR. Early surgery in patients with mitral regurgitation due to flail leaflets: a long-term outcome study. Circulation. Sep 16 1997;96(6):1819-25. [Medline].

  36. MacMahon SW, Hickey AJ, Wilcken DE, Wittes JT, Feneley MP, Hickie JB. Risk of infective endocarditis in mitral valve prolapse with and without precordial systolic murmurs. Am J Cardiol. Jan 1 1987;59(1):105-8. [Medline].

  37. MacMahon SW, Roberts JK, Kramer-Fox R, et al. Mitral valve prolapse and infective endocarditis. Am Heart J. May 1987;113(5):1291-8. [Medline].

  38. Markiewicz W, Stoner J, London E, Hunt SA, Popp RL. Mitral valve prolapse in one hundred presumably healthy young females. Circulation. Mar 1976;53(3):464-73. [Medline].

  39. Marks AR, Choong CY, Sanfilippo AJ, et al. Identification of high-risk and low-risk subgroups of patients with mitral-valve prolapse. N Engl J Med. Apr 20 1989;320(16):1031-6. [Medline].

  40. Martínez-Rubio A, Schwammenthal Y, Schwammenthal E, Block M, Reinhardt L, Garcia-Alberola A. Patients with valvular heart disease presenting with sustained ventricular tachyarrhythmias or syncope: results of programmed ventricular stimulation and long-term follow-up. Circulation. Jul 15 1997;96(2):500-8. [Medline].

  41. Mylonakis E, Calderwood SB. Infective endocarditis in adults. N Engl J Med. Nov 1 2001;345(18):1318-30. [Medline].

  42. Nidorf SM, Weyman AE, Hennessey R. The relationship between mitral valve morphology and prognosis in patients with mitral valve prolapse: a prospective echocardiographic study of 568 patients [abstr]. J Am Soc Echocardiogr. 1993;6:S8.

  43. Nishimura RA, McGoon MD. Perspectives on mitral-valve prolapse. N Engl J Med. Jul 1 1999;341(1):48-50. [Medline].

  44. Nishimura RA, McGoon MD, Shub C, Miller FA Jr, Ilstrup DM, Tajik AJ. Echocardiographically documented mitral-valve prolapse. Long-term follow-up of 237 patients. N Engl J Med. Nov 21 1985;313(21):1305-9. [Medline].

  45. Olson LJ, Subramanian R, Ackermann DM, Orszulak TA, Edwards WD. Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. Mayo Clin Proc. Jan 1987;62(1):22-34. [Medline].

  46. Orencia AJ, Petty GW, Khandheria BK, Annegers JF, Ballard DJ, Sicks JD. Risk of stroke with mitral valve prolapse in population-based cohort study. Stroke. Jan 1995;26(1):7-13. [Medline].

  47. Petty GW, Orencia AJ, Khandheria BK, Whisnant JP. A population-based study of stroke in the setting of mitral valve prolapse: risk factors and infarct subtype classification. Mayo Clin Proc. Jul 1994;69(7):632-4. [Medline].

  48. Procacci PM, Savran SV, Schreiter SL, Bryson AL. Prevalence of clinical mitral-valve prolapse in 1169 young women. N Engl J Med. May 13 1976;294(20):1086-8. [Medline].

  49. Sandok BA, Giuliani ER. Cerebral ischemic events in patients with mitral valve prolapse. Stroke. Jul-Aug 1982;13(4):448-50. [Medline].

  50. Savage DD, Devereux RB, Garrison RJ, et al. Mitral valve prolapse in the general population. 2. Clinical features: the Framingham Study. Am Heart J. Sep 1983;106(3):577-81. [Medline].

  51. Savage DD, Garrison RJ, Devereux RB, Castelli WP, Anderson SJ, Levy D. Mitral valve prolapse in the general population. 1. Epidemiologic features: the Framingham Study. Am Heart J. Sep 1983;106(3):571-6. [Medline].

  52. Savage DD, Levy D, Garrison RJ, Castelli WP, Kligfield P, Devereux RB. Mitral valve prolapse in the general population. 3. Dysrhythmias: the Framingham Study. Am Heart J. Sep 1983;106(3):582-6. [Medline].

  53. Scharf RE, Hennerici M, Bluschke V, Lueck J, Kladetzky RG. Cerebral ischemia in young patients: it is associated with mitral valve prolapse and abnormal platelet activity in vivo?. Stroke. Jul-Aug 1982;13(4):454-8. [Medline].

  54. Tieleman RG, Crijns HJ, Wiesfeld AC, Posma J, Hamer HP, Lie KI. Increased dispersion of refractoriness in the absence of QT prolongation in patients with mitral valve prolapse and ventricular arrhythmias. Br Heart J. Jan 1995;73(1):37-40. [Medline].

  55. Tse HF, Lau CP, Cheng G. Relation between mitral regurgitation and platelet activation. J Am Coll Cardiol. Dec 1997;30(7):1813-8. [Medline].

  56. Ulgen MS, Biyik I, Karadede A, Temamogullari AV, Alan S, Toprak N. Relation between QT dispersion and ventricular arrhythmias in uncomplicated isolated mitral valve prolapse. Jpn Circ J. Dec 1999;63(12):929-33. [Medline].

  57. Warth DC, King ME, Cohen JM, Tesoriero VL, Marcus E, Weyman AE. Prevalence of mitral valve prolapse in normal children. J Am Coll Cardiol. May 1985;5(5):1173-7. [Medline].

  58. Zipes DP, Libby P, Bonow RO, Braunwald E. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 7th ed. Philadelphia, Pa: Saunders; 2005.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

mitral valve prolapse, MVP, myxomatous mitral valve, floppy mitral valve syndrome, Barlow's syndrome, Barlow syndrome, billowing mitral cusp syndrome, systolic click-murmur syndrome, myxomatous mitral valve, redundant cusp syndrome, irritable heart, effort syndrome, soldier's heart, isolated mitral regurgitation, MVP syndrome

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Bhavik V Thakkar, MD, Associate Faculty, Department of Medical Education, Abbott Northwestern Hospital; Consulting Staff, Department of Medicine, Regency Hospital
Bhavik V Thakkar, MD is a member of the following medical societies: American College of Physicians-American Society of Internal Medicine, American Heart Association, American Medical Association, American Stroke Association, and Minnesota Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Alan D Forker, MD, Professor of Medicine, Program Director of Cardiovascular Fellowship, MidAmerica Heart Institute, University of Missouri at Kansas City School of Medicine; Director, Outpatient Lipid Diabetes Research Center, MidAmerica Heart Institute of Saint Luke's Hospital
Alan D Forker, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American College of Physicians, American Heart Association, American Medical Association, American Society of Hypertension, and Phi Beta Kappa
Disclosure: Research Grant Grant/research funds Hospital contracts to do research; I am a hospital employee with no personal profit; Speakers Bureau Honoraria Speaking and teaching

Adam E Schussheim, MD, Consulting Staff, Department of Internal Medicine, Bridgeport Hospital of the Yale-New Haven Medical Center
Disclosure: Nothing to disclose.

Medical Editor

Justin D Pearlman, MD, PhD, ME, MA, Director of Dartmouth Advanced Imaging Center, Professor of Medicine, Professor of Radiology, Adjunct Professor, Thayer Bioengineering and Computer Science, Dartmouth-Hitchcock Medical Center
Justin D Pearlman, MD, PhD, ME, MA is a member of the following medical societies: American College of Cardiology, American College of Physicians, American Federation for Medical Research, International Society for Magnetic Resonance in Medicine, and Radiological Society of North America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Marschall S Runge, MD, PhD, Charles and Anne Sanders Distinguished Professor of Medicine, Chairman of Medicine, Vice Dean for Clinical Affairs, Chairman, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine
Marschall S Runge, MD, PhD is a member of the following medical societies: American Association for the Advancement of Science, American College of Cardiology, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Federation for Medical Research, American Heart Association, American Physiological Society, American Society for Clinical Investigation, American Society for Investigative Pathology, Association of American Physicians, Association of Professors of Cardiology, Association of Professors of Medicine, Southern Society for Clinical Investigation, and Texas Medical Association
Disclosure: Pfizer Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Orthoclinica Diagnostica Consulting fee Consulting

CME Editor

Amer Suleman, MD, Consultant in Electrophysiology and Cardiovascular Medicine, Department of Internal Medicine, Division of Cardiology, Medical City Dallas Hospital
Amer Suleman, MD is a member of the following medical societies: American College of Physicians, American Heart Association, American Institute of Stress, American Society of Hypertension, Federation of American Societies for Experimental Biology, Royal Society of Medicine, and Society of Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

Chief Editor

Richard A Lange, MD, E Cowles Andrus Professor of Cardiology, Professor of Medicine, Johns Hopkins University School of Medicine
Richard A Lange, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Cardiology, American Heart Association, and Association of Subspecialty Professors
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.