Mitral Valve Prolapse in Emergency Medicine 

  • Author: Michael C Plewa, MD; Chief Editor: David FM Brown, MD   more...
 
Updated: Jun 27, 2011
 

Background

Mitral valve prolapse (MVP) can occur in a multitude of disorders and, in most instances, it reflects a normal variant rather than a single disease process.

Despite years of research, the symptomatology and significance of mitral valve prolapse remain controversial. It was termed the disease of the decade in the 1980s, but now some consider it an interesting finding of dubious importance until mitral regurgitation (MR) manifests. Initial studies that reported associated symptoms of MVP as chest pain, dyspnea, anxiety, and panic were probably flawed by recruitment bias.[1] Studies imply that the incidence of MVP previously was overestimated by inaccurate echocardiographic diagnostic criteria and that associated symptoms, other than palpitations, are uncommon.[2]

Despite this, patients with MVP are at risk for arrhythmias, endocarditis, stroke,[3] mitral regurgitation (MR), mitral valve replacement (MVR) surgery,[4] and sudden death. Mitral valve prolapse is also associated with migraine (especially migraine with aura),[5] autoimmune disease,[6] and idiopathic sudden sensorineural hearing loss[7] .

Mitral valve prolapse is shown in the image below.

Mitral valve prolapse. A patient with straight bacMitral valve prolapse. A patient with straight back syndrome.
Next

Pathophysiology

A myxomatous degeneration from collagen dissolution leads to excess mucopolysaccharides in the middle spongiosa layer of the mitral valve leaflets, resulting in stretching of the leaflets and the chordae tendineae. Mitral valve prolapse (MVP) occurs when the left ventricular (LV) size is small in comparison to an enlarged mitral annulus, leaflets, or chordae tendineae, and it can be induced in healthy women with typical body habitus following dehydration that is reversed with rehydration. Mitral valve prolapse resolves during pregnancy and following weight gain in anorexic patients.

Studies have shown that abnormalities of elastic fibers found in floppy mitral valves are related to genetic variants in fibrillin, one of the components of the microfibrils, as well as elastin and collagen I and II.[8] Mitral valve prolapse is associated with a variety of medical conditions involving connective tissues, such as joint hypermobility disorders,[9] and Ehlers Danlos and Marfan syndromes. Mitral valve prolapse is also associated with autoimmune disorders such as systemic lupus erythematosus and autoimmune thyroid disease; many patients with mitral valve prolapse have positive autoantibodies including ANA, rheumatoid factor, and anticardiolipin antibody.[6]

A constellation of abnormalities (eg, increased sensitivity to adrenergic stimuli, increased catecholamines, abnormal beta-receptors, increased atrial natriuretic factor, renin-aldosterone dysregulation, decreased intravascular volume, magnesium deficiency)[10] has been thought to lead to chest pain, dyspnea, fatigue, dizziness, near-syncope symptoms, and anxiety in a subset of patients with mitral valve prolapse.[11, 12]

Cardiac manifestations include supraventricular more so than ventricular arrhythmias, palpitations, mitral regurgitation, bacterial endocarditis, and sudden death. Chest pain may not be more common in patients with mitral valve prolapse than in the general population, and it may be attributed to myofascial syndromes, hyperventilation, coronary spasm, esophageal dysmotility, or gastroesophageal reflux.[13]

Mitral valve prolapse can result in cerebrovascular ischemia, which may be related to abnormal platelet activity or coagulation disorders (eg, anticardiolipin antibody, protein C or S deficiencies).

Previous
Next

Epidemiology

Frequency

United States

Mitral valve prolapse (MVP) can be identified by echocardiography in 3-4% of the general population, and it is identified in 7% of autopsies.

International

The worldwide incidence of mitral valve prolapse is similar to that in the United States.

Mortality/Morbidity

  • In general, mitral valve prolapse (MVP) is initially a benign disorder, but it may account for the majority of isolated cases of mitral regurgitation (MR), 90% of cases of ruptured chordae tendineae, 40% of strokes in young patients, and 10-15% of cases of endocarditis.
  • Those with structural abnormalities (ie, thickened, deformed, or redundant mitral valve leaflets) are more likely to suffer complications (eg, progressive MR, endocarditis, sudden death), although a longitudinal study of 285 residents in Olmsted County, MN, suggests that progression of MR occurs in nearly 40% of MVP cases, regardless of age, gender, leaflet thickening, or initial grade of MR.[14]
  • Left ventricular (LV) remodeling, with elevated LV end-systolic volume index and LV end-systolic dimension, occurs even with isolated late systolic MR murmur similar to that seen with pan-systolic MR murmur.[15]
  • Cases of MVP with a murmur and not just an isolated click have a general mortality rate that is increased by 15-20%.

Race

Prevalence is similar among different ethnic groups.[16]

Sex

  • The female-to-male ratio is approximately 3:1.
  • Men have a higher risk than women of endocarditis, posterior prolapse, leaflet thickening, severe regurgitation, and are more likely to undergo mitral valve surgery.[17]

Age

Age of onset is 10-16 years.

  • Mitral valve prolapse (MVP) is uncommon before the adolescent growth spurt occurs. It usually is detected in young adulthood.
  • Although MVP is considered congenital, echocardiographic findings typically are absent in newborns.
Previous
Proceed to Clinical Presentation
 
 
Contributor Information and Disclosures
Author

Michael C Plewa, MD  Research Coordinator, Consulting Staff, Department of Emergency Medicine, Lucas County Emergency Physicians, Inc, and Mercy Saint Vincent 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, Department of Emergency Medicine, Wood County Hospital

Richard Worthington 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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Paul Blackburn, DO, FACOEP, FACEP  Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

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.

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  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, 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: Nothing to disclose.

References

  1. Filho AS, Maciel BC, Martín-Santos R, Romano MM, Crippa JA. Does the association between mitral valve prolapse and panic disorder really exist?. Prim Care Companion J Clin Psychiatry. 2008;10(1):38-47. [Medline]. [Full Text].

  2. 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].

  3. Avierinos JF, Brown RD, Foley DA. Cerebral ischemic events after diagnosis of mitral valve prolapse: a community-based study of incidence and predictive factors. Stroke. Jun 2003;34(6):1339-44. [Medline].

  4. Singh RG, Cappucci R, Kramer-Fox R, et al. Severe mitral regurgitation due to mitral valve prolapse: risk factors for development, progression, and need for mitral valve surgery. Am J Cardiol. Jan 15 2000;85(2):193-8. [Medline].

  5. Termine C, Trotti R, Ondei P, Gamba G, Montani N, Gamba A, et al. Mitral valve prolapse and abnormalities of haemostasis in children and adolescents with migraine with aura and other idiopathic headaches: a pilot study. Acta Neurol Scand. Oct 5 2009;[Medline].

  6. Evangelopoulos ME, Toumanidis S, Sotou D, Evangelopoulos C, Mavrikakis M, Alevizaki M, et al. Mitral valve prolapse in young healthy individuals. An early index of autoimmunity?. Lupus. Apr 2009;18(5):436-40. [Medline].

  7. Vazquez R, Solanellas J, Alfageme I, Valenzuela-García LF, Pavon R, Leal J, et al. Mitral valve prolapse and sudden deafness. Int J Cardiol. Mar 14 2008;124(3):370-1. [Medline].

  8. Chou HT, Shi YR, Hsu Y. Association between fibrillin-1 gene exon 15 and 27 polymorphisms and risk of mitral valve prolapse. J Heart Valve Dis. Jul 2003;12(4):475-81. [Medline].

  9. Cavenaghi S, Marino LH, Oliveira PP, Lamari NM. Joint hypermobility in patients with mitral valve prolapse. Arq Bras Cardiol. Sep 2009;93(3):307-11. [Medline].

  10. Lichodziejewska B, Klos J, Rezler J, et al. Clinical symptoms of mitral valve prolapse are related to hypomagnesemia and attenuated by magnesium supplementation. Am J Cardiol. Mar 15 1997;79(6):768-72. [Medline].

  11. Scordo KA. Mitral valve prolapse syndrome: interventions for symptom control. Dimens Crit Care Nurs. Jul-Aug 1998;17(4):177-86. [Medline].

  12. Fontana ME, Sparks EA, Boudoulas H, Wooley CF. Mitral valve prolapse and the mitral valve prolapse syndrome. Curr Probl Cardiol. May 1991;16(5):309-75. [Medline].

  13. Kao CH, Tsai SC, Hsieh JF, et al. Radionuclide esophageal transit test to detect esophageal disorders in patients with mitral valve prolapse. Nuklearmedizin. 2000;39(4):92-6. [Medline].

  14. Avierinos JF, Detaint D, Messika-Zeitoun D, Mohty D, Enriquez-Sarano M. Risk, determinants, and outcome implications of progression of mitral regurgitation after diagnosis of mitral valve prolapse in a single community. Am J Cardiol. Mar 1 2008;101(5):662-7. [Medline].

  15. Ahmed MI, Sanagala T, Denney T, Inusah S, McGiffin D, Knowlan D, et al. Mitral valve prolapse with a late-systolic regurgitant murmur may be associated with significant hemodynamic consequences. Am J Med Sci. Aug 2009;338(2):113-5. [Medline].

  16. Theal M, Sleik K, Anand S. Prevalence of mitral valve prolapse in ethnic groups. Can J Cardiol. Apr 2004;20(5):511-5. [Medline].

  17. Avierinos JF, Inamo J, Grigioni F, Gersh B, Shub C, Enriquez-Sarano M. Sex differences in morphology and outcomes of mitral valve prolapse. Ann Intern Med. Dec 2 2008;149(11):787-95. [Medline].

  18. Devereux RB, Kramer-Fox R, Kligfield P. Mitral valve prolapse: causes, clinical manifestations, and management. Ann Intern Med. Aug 15 1989;111(4):305-17. [Medline].

  19. Tamam L, Ozpoyraz N, San M, Bozkurt A. Association between idiopathic mitral valve prolapse and panic disorder. Croat Med J. Dec 2000;41(4):410-6. [Medline].

  20. Raggi P, Callister TQ, Lippolis NJ, Russo DJ. Is mitral valve prolapse due to cardiac entrapment in the chest Cavity? A CT view. Chest. Mar 2000;117(3):636-42. [Medline].

  21. Han L, Ho TF, Yip WC, Chan KY. Heart rate variability of children with mitral valve prolapse. J Electrocardiol. Jul 2000;33(3):219-24. [Medline].

  22. Kochiadakis GE, Parthenakis FI, Zuridakis EG, et al. Is there increased sympathetic activity in patients with mitral valve prolapse?. Pacing Clin Electrophysiol. Nov 1996;19(11 Pt 2):1872-6. [Medline].

  23. Freed LA, Acierno JS, Dai D. A locus for autosomal dominant mitral valve prolapse on chromosome 11p15.4. Am J Hum Genet. Jun 2003;72(6):1551-9. [Medline].

  24. Cetinkaya M, Semizel E, Bostan O, Cil E. Risk of vasovagal syncope and cardiac arrhythmias in children with mitral valve prolapse. Acta Cardiol. Jun 2008;63(3):395-8. [Medline].

  25. Guven B, Eroglu AG, Babaoglu K, Demir T, Güzeltas A, Oztunc F, et al. QT dispersion and diastolic functions in differential diagnosis of primary mitral valve prolapse and rheumatic mitral valve prolapse. Pediatr Cardiol. Mar 2008;29(2):352-8. [Medline].

  26. Ozkan M, Kaymaz C, Dinckal H, et al. Single-photon emission computed tomographic myocardial perfusion imaging in patients with mitral valve prolapse. Am J Cardiol. Feb 15 2000;85(4):516-8, A11. [Medline].

  27. Han Y, Peters DC, Salton CJ, Bzymek D, Nezafat R, Goddu B, et al. Cardiovascular magnetic resonance characterization of mitral valve prolapse. JACC Cardiovasc Imaging. May 2008;1(3):294-303. [Medline].

  28. Hirata K, Pulerwitz T, Sciacca R, Otsuka R, Oe Y, Fujikura K, et al. Clinical utility of new real time three-dimensional transthoracic echocardiography in assessment of mitral valve prolapse. Echocardiography. May 2008;25(5):482-8. [Medline].

  29. Feuchtner GM, Alkadhi H, Karlo C, Sarwar A, Meier A, Dichtl W, et al. Cardiac CT angiography for the diagnosis of mitral valve prolapse: comparison with echocardiography1. Radiology. Feb 2010;254(2):374-83. [Medline].

  30. [Guideline] Salem DN, O'Gara PT, Madias C, Pauker SG. Valvular and structural heart disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. Jun 2008;133(6 Suppl):593S-629S. [Medline].

  31. Karakurum B, Topcu S, Yildirim T. Silent cerebral infarct in patients with mitral valve prolapse. Int J Neurosci. Nov 2005;115(11):1527-37. [Medline].

  32. [Guideline] Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation. Oct 9 2007;116(15):1736-54. [Medline].

  33. [Guideline] Gould FK, Elliott TS, Foweraker J. Guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother. Jun 2006;57(6):1035-42. [Medline].

  34. Berbarie RF, Roberts WC. Frequency of atrial fibrillation in patients having mitral valve repair or replacement for pure mitral regurgitation secondary to mitral valve prolapse. Am J Cardiol. Apr 1 2006;97(7):1039-44. [Medline].

  35. Turker Y, Ozaydin M, Acar G, Ozgul M, Hoscan Y, Varol E, et al. Predictors of atrial arrhythmias in patients with mitral valve prolapse. Acta Cardiol. Dec 2009;64(6):755-60. [Medline].

  36. Turker Y, Ozaydin M, Acar G, Ozgul M, Hoscan Y, Varol E, et al. Predictors of ventricular arrhythmias in patients with mitral valve prolapse. Int J Cardiovasc Imaging. Feb 2010;26(2):139-45. [Medline].

  37. Avierinos JF, Gersh BJ, Melton LJ. Natural history of asymptomatic mitral valve prolapse in the community. Circulation. Sep 10 2002;106(11):1355-61. [Medline].

  38. Bobkowski W, Siwinska A, Zachwieja J. A prospective study to determine the significance of ventricular late potentials in children with mitral valvar prolapse. Cardiol Young. Jul 2002;12(4):333-8. [Medline].

  39. [Guideline] Bonow RO, Carabello B, de Leon AC, et al. ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease. Executive Summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Val. J Heart Valve Dis. Nov 1998;7(6):672-707. [Medline].

  40. Freed LA, Benjamin EJ, Levy D. 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].

  41. 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].

  42. Kitlinski M, Stepniewski M, Nessler J. Is magnesium deficit in lymphocytes a part of the mitral valve prolapse syndrome?. Magnes Res. Mar 2004;17(1):39-45. [Medline].

  43. La Vecchia L, Ometto R, Centofante P, et al. Arrhythmic profile, ventricular function, and histomorphometric findings in patients with idiopathic ventricular tachycardia and mitral valve prolapse: clinical and prognostic evaluation. Clin Cardiol. Oct 1998;21(10):731-5. [Medline].

  44. Leung DY, Dawson IG, Thomas JD, Marwick TH. Accuracy and cost-effectiveness of exercise echocardiography for detection of coronary artery disease in patients with mitral valve prolapse. Am Heart J. Dec 1997;134(6):1052-7. [Medline].

 
Previous
Next
 
Mitral valve prolapse. A patient with straight back syndrome.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
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.