eMedicine Specialties > Emergency Medicine > Cardiovascular

Mitral Valve Prolapse: Follow-up

Author: Michael C Plewa, MD, Research Coordinator, Consulting Staff, Department of Emergency Medicine, Lucas County Emergency Physicians, Inc, and Saint Vincent Mercy Medical Center
Coauthor(s): Richard Worthington, MD, Assistant Clinical Professor, Program Instructor, Department of Emergency Medicine, St Vincent Mercy Medical Center
Contributor Information and Disclosures

Updated: Dec 22, 2008

Follow-up

Further Inpatient Care

  • Patients with stroke, risk of sudden death, unstable ventricular dysrhythmias, severe symptomatic mitral regurgitation (MR), or bacterial endocarditis may require inpatient management.

Further Outpatient Care

  • Consultation by a cardiologist is recommended to confirm the diagnosis, to exclude other possible disorders from the diagnosis (eg, hypertrophic cardiomyopathy, atrial septal defect) and to further evaluate symptoms (eg, palpitations).
  • Echocardiography may not be necessary for diagnosis in many cases because dynamic auscultation may be more reliable.
  • Cognitive behavioral therapy and breathing retraining may diminish functional cardiac symptoms (eg, chest pain, dyspnea, dizziness).
  • Follow-up care by a cardiothoracic surgeon is recommended for patients with hemodynamically significant MR. Surgical repair or replacement of the mitral valve is indicated for patients with exertional dyspnea, an ejection fraction below 50%, and a left ventricular end-systolic dimension approaching 45 mm.

Deterrence/Prevention

  • Blood pressure control may diminish the risk of progression to mitral regurgitation (MR).
  • Exercise; biofeedback; meditation; and avoidance of smoking, alcohol, caffeine, and stimulants may prevent symptoms.

Complications

  • For the following complications, the absolute risk (ie, annual incidence) and the odds ratios (OR), comparing patients with mitral valve prolapse (MVP) to the general population, are as follows:
    • Sudden cardiac death - 0.06% annual incidence among patients with MVP and severe MR; OR of 50-100 with hemodynamically significant MR and depressed left ventricular function
    • Rupture of chordae tendineae (the most frequent serious complication of MVP)
    • Progressive MR - 0.06% annual incidence of requiring surgery; lifetime risk of surgery is 1.5% for women and 4-6% for men; OR of 30-40; increased risk in males, older than 75 years, elevated body weight, and high blood pressure.
    • Stroke - 0.02% annual incidence versus less than 0.02% in uncomplicated MVP; OR of 4-6
    • Infective endocarditis - 0.02% annual incidence; OR of 3-8; 1 in 1400 patients per year with MVP and murmur; increased risk in males older than 45 years
    • Atrial fibrillation can be persistent in 15% or paroxysmal in 13% when MR is severe enough to require mitral valve replacement (MVR) surgery. These rates are lower than seen with mitral stenosis requiring MVR.21

Prognosis

  • In most situations, the prognosis for patients with MVP is excellent.
  • MR is the most significant risk factor for other complications (eg, sudden death, stroke, endocarditis).
  • Patients whose echo shows abnormal valve anatomy, men, and those older than 45 years are at an increased risk of developing MR.
  • Patients who are older, lack social support, have higher anxiety, and fail to exercise regularly are at risk for more symptoms.
  • Cardiovascular mortality is predicted the most by moderate-to-severe MR and ejection fraction less than 50%, and less so by left atrial size greater than 40 mm, flail leaflet, atrial fibrillation, and age older than 50 years.22

Patient Education

  • Patients with a murmur, patients who have echo evidence of nontrivial MR, or men older than 45 years who have valve thickening should inform their dentist and surgeon, although antibiotic prophylaxis prior to dental, respiratory, or infected skin or musculoskeletal tissue procedures would only be indicated if there was a history of infective endocarditis.19
  • Patients with palpitations should avoid caffeine, alcohol, stimulants, and smoking.
  • Symptoms of the classic mitral valve prolapse (MVP) syndrome may improve with exercise, meditation, and biofeedback.
  • For excellent patient education resources, visit eMedicine's Heart Center. Also, see eMedicine's patient education articles Mitral Valve Prolapse, Chest Pain, and Palpitations.

Miscellaneous

Medicolegal Pitfalls

  • Evidence of mitral valve prolapse (MVP) should not be an excuse to terminate further diagnostic evaluation of patients with symptoms such as chest pain, palpitations, dyspnea, or syncope.

Special Concerns

  • MVP does not predispose women to any increased risk during pregnancy.
  • Aviators with MVP may develop MR under positive-G force and may be at risk for dysrhythmia or syncope.
  • MVP should be considered in the differential diagnosis of patients with unexplained cerebral ischemia.18
  • Patients with MVP and a murmur should avoid high-intensity competitive sports if they have syncope associated with dysrhythmia, a family history of sudden death associated with MVP, significant supraventricular or ventricular dysrhythmias, or moderate-to-severe MR. Those who have had a previous embolic event also should avoid high-intensity competitive sports.
  • MVP is the third most common cause of sudden death in athletes, following congenital coronary artery anomalies and hypertrophic cardiomyopathy.
 


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
Multimedia: Mitral Valve Prolapse
References
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References

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Further Reading

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Contributor Information and Disclosures

Author

Michael C Plewa, MD, Research Coordinator, Consulting Staff, Department of Emergency Medicine, Lucas County Emergency Physicians, Inc, and Saint Vincent Mercy Medical Center
Michael C Plewa, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Physicians for Social Responsibility, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Richard Worthington, MD, Assistant Clinical Professor, Program Instructor, Department of Emergency Medicine, St Vincent Mercy Medical Center
Richard Worthington, MD is a member of the following medical societies: American College of Emergency Physicians, Ohio State Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Robert M McNamara, MD, FAAEM, Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine
Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Paul Blackburn, DO, FACOEP, FACEP, Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona
Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Schering  Honoraria Speaking and teaching

 
 
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