Mitral Valve Prolapse Workup

Updated: Mar 23, 2022
  • Author: Qurat-ul-ain Jelani, MD; Chief Editor: Richard A Lange, MD, MBA  more...
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Two-dimensional (2D) transthoracic echocardiography (TTE)

TTE is the most important study for diagnosing mitral valve prolapse (MVP).

Perloff et al set the stage for accurately diagnosing MVP by expanding the diagnostic standards to include clinical and echocardiographic criteria. [41, 42]

In a Framingham Heart Study, Freed et al historically described echocardiographic criteria for MVP as classic versus nonclassic (see below). [3]

Use of the parasternal long-axis view reduces the overdiagnosis of MVP. [43]

Echocardiographic findings/diagnostic criteria are as follows:

  • Classic MVP: The parasternal long-axis view shows more than 2-mm superior displacement of the mitral leaflets into the left atrium during systole, with a leaflet thickness of at least 5 mm.

  • Nonclassic MVP: Displacement is more than 2 mm, with a maximal leaflet thickness below 5 mm.

  • Other: Other echocardiographic findings that should be considered as criteria are leaflet thickening, redundancy, annular dilatation, and chordal elongation.

2D and 3D Transesophageal echocardiography (TEE)

2D-TEE takes into account several planes of imaging and is thus considered more effective in identifying prolapsing mitral valve segments. [44] 3D TEE, however, can simulate the surgeon’s view of the mitral valve and has become an essential tool in the intraoperative setting. [45]

Cardiac magnetic resonance imaging (cMRI)

CMRI represents a novel noninvasive imaging method that can identify MVP with a sensitivity and specificity of 100%, using  2D TTE as the gold standard. [46] CMRI can also serve as an important tool for follow-up of patients with MVP-related moderate to severe MR for quantitative assessment of ventricular volumes and function. [47] It can also provide insight into the biology of MV; CMRI has shown gadolinium enhancement in both the MV and papillary muscle tips in patients with MVP but not in normal subjects. [46] It is postulated that the papillary muscle is altered in MVP by repetitive traction exerted by the prolapsing leaflets. [48] CMRI-determinants of MVP-related MR include anterior leaflet length, posterior leaflet displacement, and the presence of flail leaflets. [47]

A 2015 study used CMRI for identifying the structural hallmarks of patients with MVP who had complex ventricular arrhythmias. Briefly, all patients had CMRI findings of left ventricular fibrosis at the level of papillary muscles and in the inferobasal regions. These findings correlated with autopsy findings of sudden cardiac death (SCD} in patients with MVP.


Other Imaging Studies

Contrast ventriculography

Contrast ventriculography can also help in defining mitral valve prolapse (MVP) with or without mitral regurgitation (MR). However, with the advent of echocardiography, this study is rarely necessary.

Chest radiography

Radiographs may demonstrate the progression from asymptomatic to chronic, severe MR, with the development of cardiomegaly secondary to left atrial and left ventricular dilatation and evidence of heart failure.