Pediatric Mitral Valve Prolapse Treatment & Management

Updated: Mar 21, 2017
  • Author: Poothirikovil Venugopalan, MBBS, MD, FRCPCH; Chief Editor: Syamasundar Rao Patnana, MD  more...
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Treatment

Medical Care

Admission of patients with mitral valve prolapse (MVP) is seldom required, except in the case of complications or for consideration of surgical intervention.

In childhood, 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. Clinical and echocardiographic follow-up every 2-5 years may be appropriate.

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); however, the recommendations have undergone major changes. See Antibiotic Prophylactic Regimens for Endocarditis. [18]

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

  • Regular tooth brushing 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

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Surgical Care

Relatively recent advances have made reconstructive mitral valve surgery feasible in patients with congestive heart failure, severe mitral regurgitation (MR) secondary to mitral valve prolapse, or both. [19, 20, 21]  Some surgeons advocate robotic mitral valve repair because it is a less invasive approch with good results. [22]

Some surgeons have adopted a simplified mitral valve repair in pediatric patients with connective tissue disorders and severe MR associated with bileaflet prolapse. [23] In a retrospective (2000-2014) of 18 children (< 18 years old) with these conditions at 3 institutions treated with ring annuloplasty and Alfieri edge-to-edge repair, at median 2.4 year follow-up, 1 child died (5.6%) whereas the remaining 17 children (94.4%) had mild regurgitation or less, no stenosis or systolic anterior motion, and regression of left ventricular enlargement. Aside from the single death, no other major complications were noted. [23]

In a retrospective study (1993-2013) of 4477 children who underwent mitral valve surgery to evaluate whether surgical correction of bileaflet valve alone reduces the incidence of ventricular dysrhythmias, 5 of 8 children who had bileaflet mitral valve prolapse, a presurgical malignant ventricular arrhythmia, and an internal cardioverter-defibrillator (ICD) in place before and after surgery showed a postsurgical reduction of malignant arrythmia (ventricular fibrillation, ventricular tachycardia) and appropriate ICD shocks. [24]

For details of surgical intervention, results, postoperative care, and complications of MR, see Mitral Regurgitation.

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Consultations

A multidisciplinary approach is preferable, including the following consultation with the following specialists:

  • Pediatrician

  • Pediatric cardiologist

  • Radiologist

  • Geneticist

  • Cardiothoracic specialist

  • Physiotherapist

  • Family medicine specialist

  • Orthopedist

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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 (MVP), 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 mitral regurgitation (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 electrocardiographic (ECG) recordings obtained while doing the type of exercise they are likely to undertake.

Sudden death is extremely uncommon in mitral valve prolapse.

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Long-Term Monitoring

Patients with mitral valve prolapse (MVP) require continued follow-up care and evaluation into adult life. Note the following:

  • Repeat evaluations every 2-5 years to identify any progression.

  • Infective endocarditis prophylaxis is indicated in patients with mitral valve prolapse and mitral regurgitation (MR) while undergoing at-risk procedures. However, these recommendations have undergone major changes. For more information, see  Antibiotic Prophylactic Regimens for Endocarditis.

  • Patients with accessory pathways should have detailed electrophysiology studies and radiofrequency ablation of the accessory pathway.

  • Coronary artery anomalies should be excluded in patients with chest pain before they participate in sports.

  • Mild prolapse on echocardiography, in the absence of clinical findings (15-20% of patients), does not indicate true mitral valve prolapse syndrome. Parents and patients need to be reassured.

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