Arrhythmic complications of mitral valve prolapse
- Matthew J Sorrentino, MD, FACC
Matthew J Sorrentino, MD, FACC
- Professor of Medicine
- Pritzker School of Medicine of the University of Chicago
- Section Editors
- Catherine M Otto, MD
Catherine M Otto, MD
- Editor-in-Chief — Cardiovascular Medicine
- Section Editor — Cardiac Evaluation
- Section Editor — Valvular Disease
- Professor of Medicine
- University of Washington
- Mark S Link, MD
Mark S Link, MD
- Section Editor — Cardiac Arrhythmias
- Professor of Medicine
- Tufts Medical School
Mitral valve prolapse (MVP) is the most common cause of primary mitral regurgitation (MR) in developed countries. The diagnosis is usually suspected from cardiac auscultation and then confirmed by echocardiography. (See "Definition and diagnosis of mitral valve prolapse".)
Although the correlation between certain nonspecific symptoms and MVP remains unclear, many patients with this disorder present with palpitations and atrial or ventricular arrhythmias [1-5]. Some studies suggest that these patients are at increased risk of sudden cardiac death (SCD) compared with the general population, but the exact incidence is unknown. Furthermore, since atrial and ventricular arrhythmias are common in the general population, it is not clearly established that the incidence of arrhythmias and SCD are in fact increased in patients with MVP.
This topic will review the incidence of arrhythmias, the risk of SCD, the electrocardiographic abnormalities that can be seen, and the treatment of arrhythmias in patients with MVP. The nonarrhythmic complications of MVP, including nonspecific symptoms and major complications, such as infective endocarditis, MR, transient ischemic attacks, and cerebrovascular accidents, are discussed separately. (See "Nonarrhythmic complications of mitral valve prolapse" and "Mitral valve prolapse syndrome".)
PREVALENCE OF ARRHYTHMIAS
Several studies report a broad range in incidence of the arrhythmias in patients with mitral valve prolapse (MVP) [1-5]:
●Atrial premature beats – 35 to 90 percent
- Kligfield P, Levy D, Devereux RB, Savage DD. Arrhythmias and sudden death in mitral valve prolapse. Am Heart J 1987; 113:1298.
- Schaal SF. Ventricular arrhythmias in patients with mitral valve prolapse. Cardiovasc Clin 1992; 22:307.
- Kligfield P, Devereux RB. Is the mitral valve prolapse patient at high risk of sudden death identifiable? Cardiovasc Clin 1990; 21:143.
- Babuty D, Cosnay P, Breuillac JC, et al. Ventricular arrhythmia factors in mitral valve prolapse. Pacing Clin Electrophysiol 1994; 17:1090.
- Zuppiroli A, Mori F, Favilli S, et al. Arrhythmias in mitral valve prolapse: relation to anterior mitral leaflet thickening, clinical variables, and color Doppler echocardiographic parameters. Am Heart J 1994; 128:919.
- Kavey RE, Blackman MS, Sondheimer HM, Byrum CJ. Ventricular arrhythmias and mitral valve prolapse in childhood. J Pediatr 1984; 105:885.
- Bobkowski W, Siwińska A, Zachwieja J, et al. A prospective study to determine the significance of ventricular late potentials in children with mitral valvar prolapse. Cardiol Young 2002; 12:333.
- Freed LA, Levy D, Levine RA, et al. Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med 1999; 341:1.
- Kim S, Kuroda T, Nishinaga M, et al. Relationship between severity of mitral regurgitation and prognosis of mitral valve prolapse: echocardiographic follow-up study. Am Heart J 1996; 132:348.
- Kligfield P, Hochreiter C, Kramer H, et al. Complex arrhythmias in mitral regurgitation with and without mitral valve prolapse: contrast to arrhythmias in mitral valve prolapse without mitral regurgitation. Am J Cardiol 1985; 55:1545.
- Turker Y, Ozaydin M, Acar G, et al. Predictors of ventricular arrhythmias in patients with mitral valve prolapse. Int J Cardiovasc Imaging 2010; 26:139.
- Turker Y, Ozaydin M, Acar G, et al. Predictors of atrial arrhythmias in patients with mitral valve prolapse. Acta Cardiol 2009; 64:755.
- Berbarie RF, Roberts WC. Frequency of atrial fibrillation in patients having mitral valve repair or replacement for pure mitral regurgitation secondary to mitral valve prolapse. Am J Cardiol 2006; 97:1039.
- Grigioni F, Avierinos JF, Ling LH, et al. Atrial fibrillation complicating the course of degenerative mitral regurgitation: determinants and long-term outcome. J Am Coll Cardiol 2002; 40:84.
- Boudoulas H, Schaal SF, Stang JM, et al. Mitral valve prolapse: cardiac arrest with long-term survival. Int J Cardiol 1990; 26:37.
- Vohra J, Sathe S, Warren R, et al. Malignant ventricular arrhythmias in patients with mitral valve prolapse and mild mitral regurgitation. Pacing Clin Electrophysiol 1993; 16:387.
- Davies MJ, Moore BP, Braimbridge MV. The floppy mitral valve. Study of incidence, pathology, and complications in surgical, necropsy, and forensic material. Br Heart J 1978; 40:468.
- Chesler E, King RA, Edwards JE. The myxomatous mitral valve and sudden death. Circulation 1983; 67:632.
- Nishimura RA, McGoon MD, Shub C, et al. Echocardiographically documented mitral-valve prolapse. Long-term follow-up of 237 patients. N Engl J Med 1985; 313:1305.
- Düren DR, Becker AE, Dunning AJ. Long-term follow-up of idiopathic mitral valve prolapse in 300 patients: a prospective study. J Am Coll Cardiol 1988; 11:42.
- Anders S, Said S, Schulz F, Püschel K. Mitral valve prolapse syndrome as cause of sudden death in young adults. Forensic Sci Int 2007; 171:127.
- Sriram CS, Syed FF, Ferguson ME, et al. Malignant bileaflet mitral valve prolapse syndrome in patients with otherwise idiopathic out-of-hospital cardiac arrest. J Am Coll Cardiol 2013; 62:222.
- Alpert JS. Association between arrhythmias and mitral valve prolapse. Arch Intern Med 1984; 144:2333.
- Grigioni F, Enriquez-Sarano M, Ling LH, et al. Sudden death in mitral regurgitation due to flail leaflet. J Am Coll Cardiol 1999; 34:2078.
- European Heart Rhythm Association, Heart Rhythm Society, Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247.
- Sniezek-Maciejewska M, Dubiel JP, Piwowarska W, et al. Ventricular arrhythmias and the autonomic tone in patients with mitral valve prolapse. Clin Cardiol 1992; 15:720.
- Tieleman RG, Crijns HJ, Wiesfeld AC, et al. Increased dispersion of refractoriness in the absence of QT prolongation in patients with mitral valve prolapse and ventricular arrhythmias. Br Heart J 1995; 73:37.
- Jabi H, Burger AJ, Orawiec B, Touchon RC. Late potentials in mitral valve prolapse. Am Heart J 1991; 122:1340.
- Han Y, Peters DC, Salton CJ, et al. Cardiovascular magnetic resonance characterization of mitral valve prolapse. JACC Cardiovasc Imaging 2008; 1:294.
- Kinder C, Tamburro P, Kopp D, et al. The clinical significance of nonsustained ventricular tachycardia: current perspectives. Pacing Clin Electrophysiol 1994; 17:637.
- Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523.
- Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: valvular heart disease. J Am Coll Cardiol 2005; 45:1334.
- Maron BJ, Ackerman MJ, Nishimura RA, et al. Task Force 4: HCM and other cardiomyopathies, mitral valve prolapse, myocarditis, and Marfan syndrome. J Am Coll Cardiol 2005; 45:1340.
- PREVALENCE OF ARRHYTHMIAS
- SUDDEN CARDIAC DEATH
- Risk stratification
- Flail mitral leaflet
- ELECTROCARDIOGRAPHIC ABNORMALITIES
- ELECTROPHYSIOLOGIC TESTING
- Survivors of SCD or sustained VT
- Very symptomatic palpitations
- Mild palpitations from atrial or ventricular premature beats
- Atrial fibrillation
- Asymptomatic patients without evidence of sustained arrhythmias
- Mitral valve surgery
- Participation in sports
- SUMMARY AND RECOMMENDATIONS