Mitral Valve Prolapse Treatment & Management

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

Medical Care

Asymptomatic patients with minimal disease

Aymptomatic patients with minimal mitral valve disease should be reassured of their benign prognosis.

They should undergo initial echocardiography for risk stratification. If no clinically significant mitral regurgitation (MR) and thin leaflets are observed, clinical examinations and echocardiographic studies can be scheduled every 3-5 years.

Encourage these patients to pursue a normal, unrestricted lifestyle, including vigorous exercise.

Different measures may be aimed at orthastatic intolerance. A trial of beta-blockers for symptomatic relief can be recommended in patients with palpitations.or other symptoms of an enhanced adrenergic drive. Abstinence from stimulants such as caffeine, alcohol, and cigarettes is also recommended. An ambulatory 24-hour Holter monitor may be useful to detect supraventricular and/or ventricular arrhythmias.

Patients with evidence of progression to severe mitral regurgitation

Asymptomatic patients with moderate-to-severe MR and left ventricular enlargement, especially those with atrial fibrillation and/or pulmonary hypertension, should undergo surgery before left ventricular function deteriorates. Echocardiographic criteria for severe MR include a vena contracta width more than 0.7 cm, a large central MR jet (area >40% of the left atrium), pulmonary vein reversal, an effective regurgitant orifice more than 40 mm2, a regurgitant fraction over 50%, and a regurgitant volume over 60 mL. [47]

According to the 2014 American College of Cardiology/American Heart Association (ACC/AHA) guidelines on the treatment of patients with valvular heart disease, mitral valve surgery is indicated for asymptomatic patients with chronic severe primary MR and a left ventricular ejection fraction (LVEF) of  30-60% and/or a left ventricular end-systolic dimension (LVESD) of 40 mm or more (class 1; level of evidence: B). [48] Timing of surgery should also take into account the anatomy of the valve lesion, the likelihood of a successful repair, and the local surgical experience.

If it is unclear whether or not the patient is asymptomatic, a treadmill stress test for exercise tolerance can be performed. That is, have the patient demonstrate that he or she can walk vigorously without symptoms. 

Patients with MVP and neurologic findings

Antithrombotic therapy is not recommended in patients without a history of systemic embolism, ischemic stroke, or atrial fibrillation. However, a thorough evaluation for atrial fibrillation should be undertaken with consideration for longer term (eg, 30 day) monitoring. [49, 50] For secondary prevention, in the absence of demonstrable atrial fibrillation, antiplatelet therapy with aspirin at a dosage of 75-325 mg/day or clopidogrel 75 mg/day may be considered.

Recommend cessation of smoking and oral contraceptive use to prevent a hypercoagulable state.

Embolic events in patients with MVP and mild MR that are presumed to be secondary to paroxysmal atrial fibrillation should be treated according to general guidelines for atrial fibrillation.

Infective endocarditis prophylaxis (IE):

Endocarditis prophylaxis is no longer recommended by the current ACC/AHA guidelines for patients with MVP, except in high-risk patients and those at risk of complications from endocarditis. [47, 48, 51]

Follow-up

Depending on its severity, patients with MVP may be monitored regularly with a careful history, physical examination, and echocardiography when indicated.

If symptoms or physical findings change during outpatient care, echocardiography or other studies (ie, Holter monitor, radiography) may be indicated

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Surgical Care

In a study of 443 patients who underwent mitral valve repair formitral valve prolapse (MVP), investigators found that preoperative atrial fibrillation was a predictor of long-term mortality and postoperative left ventricular dysfunction. The investigators suggested that performing mitral valve repair surgery before the onset of atrial fibrillation may improve postoperative outcomes. [52]

In a retrospective study of 1218 patients who underwent mitral valve repair for isolated degenerative mitral regurgitation (MR), postoperative MR recurrence was associated with adverse left ventricular remodeling and late death. The investigators found a marked decrease in the incidence of MR recurrence following the first year after intervention. They recommended that patients with complex mitral valve prolapse be informed of the risk of recurrent MR during the first year after degenerative mitral valve repair. [53]

See the surgical management discussion in the Medscape article Mitral Regurgitation.

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