eMedicine Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Cardiology

Mitral Valve Prolapse: Treatment & Medication

Author: Poothirikovil Venugopalan, MBBS, MD, FRCP (Glasg), FRCPCH, Consulting Staff, Department of Child Health, University Hospital of Hartlepool, UK
Contributor Information and Disclosures

Updated: Oct 8, 2008

Treatment

Medical Care

In childhood, mitral valve prolapse (MVP) is not progressive, and specific therapy is not indicated for the vast majority of patients. Asymptomatic patients with isolated mitral systolic clicks need only counseling and reassurance.

Avoid excessive use of caffeine, cigarettes, alcohol, and prescription or over-the-counter drugs that contain stimulants such as epinephrine or ephedrine to minimize catecholamine and cyclic adenosine monophosphate (AMP) stimulation. Prevention of volume depletion before, during, and immediately after exercise may help. Subacute bacterial endocarditis antibiotic prophylaxis coverage for at-risk procedures is indicated in patients with mitral valve prolapse and mitral regurgitation (MR). See Antibiotic Prophylactic Regimens for Endocarditis.9

Additional dental care recommended for patients at risk for infective endocarditis includes the following:

  • Regular toothbrushing after eating
  • No cookies, sweets, or sweet drinks between meals
  • Regular dental checks every 6 months
  • Fluoride supplements in locations where the fluoride in drinking water is less than 0.3 ppm for children younger than 2 years or less than 0.7 ppm for children younger than 2 years
  • Dental treatments (more than 2) scheduled at an interval of 14 days or longer

Surgical Care

Recent advances have made reconstructive mitral valve surgery feasible in patients with congestive heart failure, severe MR secondary to mitral valve prolapse, or both.10 For details of surgical intervention, results, postoperative care, and complications of MR, see Mitral Regurgitation.

Consultations

A multidisciplinary approach is preferable, including the following:

  • Pediatrician
  • Pediatric cardiologist
  • Radiologist
  • Geneticist
  • Cardiothoracic specialist
  • Physiotherapist
  • Family medicine specialist
  • Orthopedist

Activity

A gradual return to exercise may be tolerated. In the absence of studies on the effect of exercise on the progression of mitral valve prolapse, the best approach at present is based on common sense and good clinical judgment.

Patients with symptoms of syncope, presyncope, or palpitations upon exertion should undergo thorough evaluations and avoid competitive sports for at least 6 months after the last significant episode. In the presence of significant MR, limitations apply as for any other cause of MR.

Coexisting aortic root dilatation and aortic regurgitation can further limit activity.

Patients with cardiac arrhythmia should have periodic exercise tests performed and ambulatory ECG recordings obtained while doing the type of exercise they are likely to undertake.

Sudden death is extremely uncommon in mitral valve prolapse.

Medication

Medical strategies for mitral valve prolapse (MVP) include the following:

  • Anticongestive heart failure therapy
  • Antibiotic prophylaxis during surgery, dental, and genitourinary procedures - Only necessary if associated MR is present (See Antibiotic Prophylactic Regimens for Endocarditis.)9
  • Antiarrhythmic therapy - May be indicated in patients with documented and/or symptomatic arrhythmia, depending on findings of noninvasive and/or invasive electrophysiologic testing
  • Beta-blockers - May be beneficial for symptom prevention, reduction in ectopy, treatment of vasodepressor syncope, panic attacks, or antiarrhythmic therapy11
  • Antiplatelet therapy - Used in patients with thromboembolic episodes
  • ACE inhibitors - Used in patients with significant MR
  • Low-dose aspirin and/or anticoagulant therapy - Considered in patients with thromboembolic episodes

Beta-adrenergic blocking agents

These agents block the beta-adrenergic receptor and are modulators of the autonomic system. They inhibit chronotropic, inotropic and vasodilatory responses to beta-adrenergic stimulation.


Propranolol (Inderal)

Inhibits beta1-adrenergic and beta2-adrenergic receptors. Class II antiarrhythmic, nonselective, beta-adrenergic receptor blocker with membrane-stabilizing activity that decreases automaticity of contractions.

Adult

30-160 mg/d PO divided tid/qid

Pediatric

1-4 mg/kg/d PO divided bid/qid

Enhances hypotensive action of ACE inhibitors, alcohol, anesthetics, corticosteroids, and diuretics; increases negative inotropic action of calcium channel blockers

Documented hypersensitivity; bronchial asthma, bradycardia, hypotension, second-degree and third-degree heart block, or severe peripheral arterial disease

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Beta-adrenergic blockade may decrease signs of acute hypoglycemia and hyperthyroidism; abrupt withdrawal may exacerbate symptoms of hyperthyroidism, including thyroid storm; slowly withdraw drug and closely monitor; reduce dose in liver or renal failure and myasthenia gravis; adverse effects include bradycardia, hypotension, bronchospasm, GI upset, fatigue, and rash; taper over 1-2 wk when discontinuing

Antiplatelet agents

These drugs are used for secondary prevention of thrombotic cerebrovascular or cardiac disease.


Aspirin (Anacin, Bayer, Empirin)

Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2.

Adult

75-100 mg/d PO

Pediatric

5-10 mg/kg/d PO; not to exceed 100 mg/d

Effects may decrease with antacids and urinary alkalinizers; corticosteroids decrease salicylate serum levels; additive hypoprothrombinemic effects and increased bleeding time may occur with coadministration of anticoagulants; may antagonize uricosuric effects of probenecid and increase toxicity of phenytoin and valproic acid; doses >2 g/d may potentiate glucose lowering effect of sulfonylurea drugs; enhanced absorption with metoclopramide; increases levels of methotrexate and acetazolamide

Documented hypersensitivity; liver damage, hypoprothrombinemia, vitamin K deficiency, bleeding disorders, asthma; due to association of aspirin with Reye syndrome, not for use in children (<16 y) with flu

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

May cause transient decrease in renal function and aggravate chronic kidney disease; avoid use in patients with severe anemia, with history of blood coagulation defects, or taking anticoagulants; use in pregnancy may cause increased risk of bleeding during delivery; high doses may cause premature closure of ductus arteriosus with complications; enhances risk of kernicterus in babies if given to mother toward term; adverse effects include bronchospasm, GI hemorrhage, and other hemorrhages


Dipyridamole (Persantine)

Acts by decreasing platelet aggregation. Inhibits thrombus formation in the arterial side of circulation.

Adult

300-600 mg/d PO divided tid/qid

Pediatric

2.5 mg/kg PO bid

Theophylline may decrease hypotensive effects; antiplatelet activity may increase heparin toxicity; enhances and prolongs action of adenosine

Documented hypersensitivity; peptic ulcer disease; hereditary coagulopathies

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in hypotension; medication has peripheral vasodilating effects; exacerbates heart failure, asthma, angina, and MI; adverse effects include GI upset, dizziness, headache, hot flushes, tachycardia, and bleeding tendency

Diuretics

These drugs are used to release retained fluid and lower preload.


Furosemide (Lasix)

Inhibits reabsorption of fluid from ascending limb of the Henle loop in renal tubule. Administered IV. Has venodilation action; thus, also lowers preload even before diuresis effect. Useful in acute heart failure and exacerbations of chronic heart failure.

Adult

40 mg PO bid; or 20-50 mg IV, repeat q6-8h

Pediatric

1-4 mg/kg PO qd or bid; or 1-4 mg/kg IV q8h

Enhanced hypotension with ACE inhibitors; enhanced risk of nephrotoxicity with nonsteroidal antiinflammatory drugs; coadministration with amiodarone causes flecainide-enhanced toxicity because of the risk of hypokalemia; possible enhanced ototoxicity with aminoglycosides; enhanced hypotension and risk of cardiac arrhythmia with sotalol

Documented hypersensitivity; hepatic coma, anuria, and state of severe electrolyte depletion

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Perform frequent serum electrolyte (monitor for hypokalemia and hyponatremia), CO2, glucose, creatinine, uric acid, calcium, and BUN level determinations during first few months of therapy and periodically thereafter; aggravates diabetes mellitus, porphyria, and liver failure; caution in pregnancy and breastfeeding


Spironolactone (Aldactone)

Potassium-sparing diuretic. Acts on the distal convoluted tubule of the kidney as an aldosterone antagonist. Has synergistic action with furosemide.

Adult

100-200 mg/d PO

Pediatric

0.5-1.5 mg/kg PO bid

Risk of hyperkalemia with ACE inhibitors, cyclosporin, or potassium supplements

Documented hypersensitivity; hyperkalemia, hyponatremia, severe renal impairment, Addison disease

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in renal and hepatic impairment; may cause GI upset, hyponatremia, hyperkalemia, lethargy, confusion, impotence, gynecomastia, and is carcinogenic in rodents


Amiloride (Midamor)

Pyrazine-carbonyl-guanidine unrelated chemically to other known antikaliuretic or diuretic agents. Potassium-conserving (antikaliuretic) drug that, compared with thiazide diuretics, possesses weak natriuretic, diuretic, and antihypertensive activity. Acts directly on the distal renal tubule, usually used along with a potassium-losing diuretic.

Adult

5-10 mg PO bid

Pediatric

<20 kg: 0.2 mg/kg PO bid; not to exceed 10 mg/d
>20 kg: Administer as in adults

Risk of hyperkalemia with ACE inhibitors, cyclosporine, or potassium supplements; decreased effect with NSAIDs

Documented hypersensitivity; elevated serum potassium levels, >5.5 mEq/L; impaired renal function, acute or chronic renal insufficiency, and evidence of diabetic nephropathy; closely monitor electrolytes if evidence of renal functional impairment, BUN level >30 mg/100 mL, or serum creatinine levels >1.5 mg/100 mL

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Potassium retention associated with use of an antikaliuretic agent accentuated in presence of renal impairment and may result in rapid development of hyperkalemia; monitor serum potassium level, mild hyperkalemia usually not associated with abnormal ECG; GI upset, dry mouth, skin rash, confusion, and postural hypotension may develop

ACE inhibitors

These agents reduce afterload and decrease myocardial remodeling, which worsens chronic heart failure.


Captopril (Capoten)

Accepted as essential part of heart failure therapy. Not only gives symptomatic improvement but also prolongs survival.

Adult

6.25-25 mg PO tid

Pediatric

0.1-1 mg/kg PO tid; initiate at lower dosage range and titrate upward

NSAIDs may reduce hypotensive effects of captopril; ACE inhibitors may increase digoxin, lithium, and allopurinol levels; rifampin decreases levels; probenecid may increase levels; the hypotensive effects of ACE inhibitors may be enhanced when given concurrently with diuretics;
enhanced hypotensive effect with coadministration of anesthetic agents; cyclosporine enhances risk of hyperkalemia; potassium-sparing diuretics or potassium supplements enhance risk of hyperkalemia

Documented hypersensitivity; renal artery stenosis, left ventricular outflow obstruction

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Category D in second and third trimesters; caution in renal impairment, valvular stenosis, or severe congestive heart failure; adverse effects include hypotension, tachycardia, and renal failure; therapy must be commenced while blood pressure is adequate and state of hydration satisfactory; small doses are started while in hospital and blood pressure is monitored; persistent dry cough has been reported in 5-20% of children and may require change to another agent in the group or to an angiotensin receptor blocker; other adverse effects include angioedema, rash, serum sickness, GI upset, pancreatitis, hepatitis, cholestatic jaundice, blood dyscrasias, bronchospasm, headache, dizziness, and fatigue

Cardiac glycoside

These agents provide symptomatic improvement in heart failure.


Digoxin (Lanoxin)

Improves myocardial contractility, reduces heart rate, and lowers sympathetic stimulation in chronic heart failure.

Adult

Maintenance: 125-250 mcg/d PO

Pediatric

Maintenance dose:
Preterm infant: 5-7.5 mcg/kg/d PO
Term infant: 6-10 mcg/kg/d PO
1 month to 2 years: 10-15 mcg/kg/d PO
2-5 years: 7.5-10 mcg/kg/d PO
5-10 years: 5-10 mcg/kg/d PO
>10 years: 2.5-5 mcg/kg/d PO
Daily dose typically divided bid if age <10 y

Medications that may increase digoxin levels include alprazolam, benzodiazepines, bepridil, captopril, cyclosporine, propafenone, propantheline, quinidine, diltiazem, aminoglycosides, amiodarone, anticholinergics, diphenoxylate, erythromycin, felodipine, flecainide, furosemide, hydroxychloroquine, itraconazole, nifedipine, omeprazole, quinine, ibuprofen, indomethacin, esmolol, tetracycline, tolbutamide, and verapamil; medications that may decrease serum digoxin levels include aminoglutethimide, antihistamines, cholestyramine, neomycin, penicillamine, aminoglycosides, PO colestipol, hydantoins, hypoglycemic agents, antineoplastic treatment combinations (including carmustine, bleomycin, methotrexate, cytarabine, doxorubicin, cyclophosphamide, vincristine, procarbazine), aluminum or magnesium antacids, rifampin, sucralfate, sulfasalazine, barbiturates, kaolin/pectin, and aminosalicylic acid

Documented hypersensitivity; beriberi heart disease, idiopathic hypertrophic subaortic stenosis, constrictive pericarditis, and Wolff-Parkinson-White syndrome

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Reduce dose in renal impairment; avoid hypokalemia; avoid IV use except when absolutely essential; avoid in sick sinus syndrome and thyroid disease; monitor blood level in suspected toxicity and in high-risk situations; major noncardiac adverse effects include vomiting, nausea, abdominal pain, visual disturbances, headache, and fatigue; cardiac adverse effects include arrhythmia (paroxysmal atrial tachycardia with block) and heart block

More on Mitral Valve Prolapse

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References
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Further Reading

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Keywords

mitral valve prolapse, Barlow syndrome, billowing mitral valve syndrome, Da Costa syndrome, effort syndrome, familial MVP, floppy mitral valve syndrome, irritable heart syndrome, myxomatous mitral valve, neuro-circulatory asthenia, redundant cusp syndrome, soldier heart syndrome, systolic click-murmur syndrome, mitral regurgitation, heart failure, Marfan syndrome, Ehlers-Danlos syndrome, rheumatic fever, endocarditis, myocardial infarction, ischemia, syncope supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, cardiac arrhythmia, panic attacks, presyncope, Stickler syndrome

polycystic kidney disease, osteogenesis imperfecta, fragile X syndrome, Martin-Bell syndrome, pseudoxanthoma elasticum, periarteritis nodosa, asthenic habitus, straight back syndrome, pectus excavatum, pectus carinatum, atrial septal defect ostium secundum, tricuspid valve prolapse, aortic valve prolapse, Ebstein anomaly, Holt-Oram syndrome, hypertrophic cardiomyopathy, Graves disease, thyroiditis, sickle cell disease, muscular dystrophy, myotonic dystrophy, Von Willebrand disease, magnesium deficiency

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Contributor Information and Disclosures

Author

Poothirikovil Venugopalan, MBBS, MD, FRCP (Glasg), FRCPCH, Consulting Staff, Department of Child Health, University Hospital of Hartlepool, UK
Poothirikovil Venugopalan, MBBS, MD, FRCP (Glasg), FRCPCH is a member of the following medical societies: British Cardiac Society, Royal College of Paediatrics and Child Health, and Royal College of Physicians and Surgeons of Glasgow
Disclosure: Nothing to disclose.

Medical Editor

Charles I Berul, MD, Associate Professor of Pediatrics, Harvard Medical School; Senior Associate, Department of Cardiology, Children's Hospital of Boston
Charles I Berul, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American Heart Association, Heart Rhythm Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Julian M Stewart, MD, PhD, Associate Chairman of Pediatrics, Director, Center for Hypotension, Westchester Medical Center; Professor of Pediatrics and Physiology, New York Medical College
Julian M Stewart, MD, PhD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

CME Editor

Gilbert Herzberg, MD, Assistant Professor, Department of Pediatrics, Section of Pediatric Cardiology, New York Medical College
Gilbert Herzberg, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Chief Editor

Stuart Berger, MD, Professor of Pediatrics, Division of Cardiology, Medical College of Wisconsin; Chief of Pediatric Cardiology, Medical Director of Pediatric Heart Transplant Program, Medical Director of The Heart Center, Children's Hospital of Wisconsin
Stuart Berger, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Cardiology, American College of Chest Physicians, American Heart Association, and Society for Cardiac Angiography and Interventions
Disclosure: Nothing to disclose.

 
 
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