Mitral Valve Prolapse Clinical Presentation

Updated: Nov 16, 2016
  • Author: Qurat-ul-ain Jelani, MD; Chief Editor: Richard A Lange, MD, MBA  more...
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Presentation

Clinical Classification

Mitral valve prolapse (MVP) can be categorized into primary or nonsyndromic MVP and secondary or syndromic MVP.

Primary/nonsyndromic MVP

In the community-based Framingham Heart Study, the prevalence of MVP was 2.4%. [1] A similar prevalence was described in a population-based sample of American Indians [2] as well as in a sample of Canadians of South Asian, European, and Chinese descent (SHARE study). [34]  Tricuspid valve prolapse has been observed in up to 40-50% of patients with primary or nonsyndromic MVP. [35]

Secondary/syndromic MVP

MVP also occurs in the presence of connective tissue disorders, such as the following [8, 9] :

  • Marfan syndrome
  • Loeys-Dietz syndrome
  • Ehlers-Danlos syndrome
  • Osteogenesis imperfecta
  • Pseudoxanthoma elasticum
  • Aneurysms-osteoarthritis syndrome
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History

Mitral valve prolapse (MVP) is often diagnosed from the physical examination, when the classic auscultatory finding of a mid-to-late systolic click and/or murmur is appreciated. Alternatively, it may be incidentally diagnosed during routine echocardiography or discovered when complications of MVP manifest.

Most patients are asymptomatic. Those with symptomatic MVP typically present with symptoms related to (1) progression of mitral regurgitation (MR), (2) an associated complication (ie, stroke, endocarditis, or arrhythmia), or (3) autonomic dysfunction (this association remains unconfirmed; see below).

Progression of MR

Symptoms related to progression of MR include the following:

  • Fatigue

  • Dyspnea

  • Exercise intolerance

  • Orthopnea

  • Paroxysmal nocturnal dyspnea (PND)

  • Progressive signs of congestive heart failure (CHF)

  • Palpitations (from associated arrhythmias)

Autonomic dysfunction

Autonomic dysfunction has been reported as the mechanism underlying symptoms in patients with MVP. The spectrum of symptoms resulting from autonomic dysfunction was previously termed as MVP syndrome. [1, 36] However, the association between MVP and autonomic dysfunction remains unconfirmed. [37]

Symptoms related to autonomic dysfunction are usually associated with genetically inherited MVP and may include the following:

  • Anxiety

  • Panic attacks

  • Arrhythmias

  • Exercise intolerance

  • Palpitations

  • Atypical chest pain

  • Fatigue

  • Orthostasis

  • Syncope or presyncope

  • Neuropsychiatric symptoms

The electrocardiogram (ECG) is usually normal, but it can show nonspecific ST-segment and T-wave abnormalities, especially in leads II, III, aVF.

As noted earlier, MVP is also commonly seen in patients with heritable connective tissue disorders.

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Physical Examination

Clinical characteristics are typically benign in young women, whereas men older than 50 years tend to have serious consequences of mitral regurgitation (MR).

Common general physical features associated with mitral valve prolapse (MVP) include the following:

  • Asthenic body habitus

  • Low body weight or body mass index (BMI)

  • Straight-back syndrome

  • Scoliosis or kyphosis

  • Pectus excavatum

  • Hypermobility of the joints

  • Arm span greater than height (which may be indicative of Marfan syndrome)

Physical findings

The classic auscultatory finding is a mid-to-late systolic click, which is present due to the leaflets prolapsing into the left atrium, thereby resulting in tensing of the mitral valve apparatus. The click may or may not be followed by a high-pitched, mid-to-late systolic murmur at the cardiac apex.

The midsystolic click can vary in intensity and timing, primarily depending on the left ventricular volume.

End-diastolic volume can be reduced by having the patient perform a Valsalva maneuver or by having the patient stand. These maneuvers result in an earlier click, closer to the first heart sound, and a prolonged murmur. They may even bring out a murmur when none is heard at rest. In the supine position, especially with the legs raised for increased venous return, left ventricular diastolic volume is increased, resulting in a click later in systole and a shortened murmur.

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