Nonarrhythmic complications of mitral valve prolapse
- Sorin Pislaru, MD, PhD
Sorin Pislaru, MD, PhD
- Professor of Medicine
- Department of Cardiovascular Diseases
- Mayo Clinic
- Maurice Enriquez-Sarano, MD
Maurice Enriquez-Sarano, MD
- Professor of Medicine
- Mayo Medical School
Mitral regurgitation (MR) is the most frequent valve disease in the United States population , with mitral valve prolapse (MVP) the most common cause of MR requiring surgical correction . While the diagnosis of MVP is relatively simple (the clinical finding of a systolic click and/or murmur leads to confirmatory echocardiography), the medical literature is somewhat confusing. This is related to the overlap between denomination of MVP clinical syndromes, etiology and mechanisms, and to a change in echocardiographic diagnostic criteria for MVP. (See "Definition and diagnosis of mitral valve prolapse".)
Major nonarrhythmic complications of MVP including MR, heart failure, infective endocarditis, and cerebrovascular accidents will be reviewed here. Other conditions associated with MVP are discussed elsewhere. (See "Mitral valve prolapse syndrome" and "Arrhythmic complications of mitral valve prolapse".)
It has been estimated that the overall risk of serious complications in MVP is about 1 percent per year in patients with clinically and echocardiographically diagnosed disease; this is a not a cumulative risk since some patients have multiple complications . However, patients with MVP can be divided into widely variable risk groups, with the high-risk group having a cardiovascular mortality of 3.4 percent per year .
The most important risk factors for mortality are presence of moderate to severe MR and left ventricular ejection fraction less than 50 percent . The severity of MR also correlates with the requirement for valve replacement and the incidence of infective endocarditis, cerebral embolism, and death (figure 1) [4,5]. (See "Natural history of chronic mitral regurgitation caused by mitral valve prolapse and flail mitral leaflet", section on 'Natural history of mitral valve prolapse'.)
Primary mitral valve prolapse (MVP) is the most common etiology of pure mitral regurgitation (MR), accounting for over 50 percent of cases; it also accounts for over 60 percent of patients with ruptured chordae tendineae .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Nkomo VT, Gardin JM, Skelton TN, et al. Burden of valvular heart diseases: a population-based study. Lancet 2006; 368:1005.
- Olson LJ, Subramanian R, Ackermann DM, et al. Surgical pathology of the mitral valve: a study of 712 cases spanning 21 years. Mayo Clin Proc 1987; 62:22.
- Zuppiroli A, Rinaldi M, Kramer-Fox R, et al. Natural history of mitral valve prolapse. Am J Cardiol 1995; 75:1028.
- Avierinos JF, Gersh BJ, Melton LJ 3rd, et al. Natural history of asymptomatic mitral valve prolapse in the community. Circulation 2002; 106:1355.
- 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.
- Devereux RB, Hawkins I, Kramer-Fox R, et al. Complications of mitral valve prolapse. Disproportionate occurrence in men and older patients. Am J Med 1986; 81:751.
- Enriquez-Sarano M, Tajik AJ, Schaff HV, et al. Echocardiographic prediction of left ventricular function after correction of mitral regurgitation: results and clinical implications. J Am Coll Cardiol 1994; 24:1536.
- Crawford MH, Souchek J, Oprian CA, et al. Determinants of survival and left ventricular performance after mitral valve replacement. Department of Veterans Affairs Cooperative Study on Valvular Heart Disease. Circulation 1990; 81:1173.
- Freed LA, Levy D, Levine RA, et al. Prevalence and clinical outcome of mitral-valve prolapse. N Engl J Med 1999; 341:1.
- Levy D, Savage D. Prevalence and clinical features of mitral valve prolapse. Am Heart J 1987; 113:1281.
- Devereux RB, Kramer-Fox R, Kligfield P. Mitral valve prolapse: causes, clinical manifestations, and management. Ann Intern Med 1989; 111:305.
- Enriquez-Sarano M, Basmadjian AJ, Rossi A, et al. Progression of mitral regurgitation: a prospective Doppler echocardiographic study. J Am Coll Cardiol 1999; 34:1137.
- 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.
- Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003; 16:777.
- Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian A, et al. Guidelines on the management of valvular heart disease (version 2012). Eur Heart J 2012; 33:2451.
- Enriquez-Sarano M, Avierinos JF, Messika-Zeitoun D, et al. Quantitative determinants of the outcome of asymptomatic mitral regurgitation. N Engl J Med 2005; 352:875.
- Pizarro R, Bazzino OO, Oberti PF, et al. Prospective validation of the prognostic usefulness of brain natriuretic peptide in asymptomatic patients with chronic severe mitral regurgitation. J Am Coll Cardiol 2009; 54:1099.
- Kang DH, Kim JH, Rim JH, et al. Comparison of early surgery versus conventional treatment in asymptomatic severe mitral regurgitation. Circulation 2009; 119:797.
- Enriquez-Sarano M, Sinak LJ, Tajik AJ, et al. Changes in effective regurgitant orifice throughout systole in patients with mitral valve prolapse. A clinical study using the proximal isovelocity surface area method. Circulation 1995; 92:2951.
- Topilsky Y, Michelena H, Bichara V, et al. Mitral valve prolapse with mid-late systolic mitral regurgitation: pitfalls of evaluation and clinical outcome compared with holosystolic regurgitation. Circulation 2012; 125:1643.
- 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.
- 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.
- Ribeiro CL, Ginefra P, Albanesi Filho FM, et al. [Prevalence of tricuspid and aortic valve prolapse in patients with mitral valve prolapse]. Arq Bras Cardiol 1989; 53:251.
- Come PC, Riley MF, Carl LV, Nakao S. Pulsed Doppler echocardiographic evaluation of valvular regurgitation in patients with mitral valve prolapse: comparison with normal subjects. J Am Coll Cardiol 1986; 8:1355.
- Yilmaz O, Suri RM, Dearani JA, et al. Functional tricuspid regurgitation at the time of mitral valve repair for degenerative leaflet prolapse: the case for a selective approach. J Thorac Cardiovasc Surg 2011; 142:608.
- Weinberger I, Rotenberg Z, Zacharovitch D, et al. Native valve infective endocarditis in the 1970s versus the 1980s: underlying cardiac lesions and infecting organisms. Clin Cardiol 1990; 13:94.
- McKinsey DS, Ratts TE, Bisno AL. Underlying cardiac lesions in adults with infective endocarditis. The changing spectrum. Am J Med 1987; 82:681.
- Castonguay MC, Burner KD, Edwards WD, et al. Surgical pathology of native valve endocarditis in 310 specimens from 287 patients (1985-2004). Cardiovasc Pathol 2013; 22:19.
- MacMahon SW, Roberts JK, Kramer-Fox R, et al. Mitral valve prolapse and infective endocarditis. Am Heart J 1987; 113:1291.
- 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.
- Marks AR, Choong CY, Sanfilippo AJ, et al. Identification of high-risk and low-risk subgroups of patients with mitral-valve prolapse. N Engl J Med 1989; 320:1031.
- Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 116:1736.
- Devereux RB, Frary CJ, Kramer-Fox R, et al. Cost-effectiveness of infective endocarditis prophylaxis for mitral valve prolapse with or without a mitral regurgitant murmur. Am J Cardiol 1994; 74:1024.
- Durack DT, Kaplan EL, Bisno AL. Apparent failures of endocarditis prophylaxis. Analysis of 52 cases submitted to a national registry. JAMA 1983; 250:2318.
- Desimone DC, Tleyjeh IM, Correa de Sa DD, et al. Incidence of infective endocarditis caused by viridans group streptococci before and after publication of the 2007 American Heart Association's endocarditis prevention guidelines. Circulation 2012; 126:60.
- Wilson W, Taubert KA, Gewitz M, et al. Prevention of Infective Endocarditis. Guidelines From the American Heart Association. A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007; 115 published online April 19, 2007. www.circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095v1 (Accessed on May 04, 2007).
- Avierinos JF, Brown RD, Foley DA, et al. Cerebral ischemic events after diagnosis of mitral valve prolapse: a community-based study of incidence and predictive factors. Stroke 2003; 34:1339.
- Gilon D, Buonanno FS, Joffe MM, et al. Lack of evidence of an association between mitral-valve prolapse and stroke in young patients. N Engl J Med 1999; 341:8.
- Wolf PA, Sila CA. Cerebral ischemia with mitral valve prolapse. Am Heart J 1987; 113:1308.
- Nichol, P, Kertesz, A. Two dimensional echocardiographic (2DE) detection of left atrial thrombosis in patient with mitral valve prolapse and strokes. Circulation 1979; 59/60 (Suppl II):18.
- Tse HF, Lau CP, Cheng G. Relation between mitral regurgitation and platelet activation. J Am Coll Cardiol 1997; 30:1813.
- Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline 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. J Am Coll Cardiol 2014; 63:e57.
- MITRAL REGURGITATION
- Role of quantification
- Natural history and role of surgery
- PROLAPSE OF OTHER VALVES
- INFECTIVE ENDOCARDITIS
- Risk factors
- TRANSIENT ISCHEMIC ATTACKS AND CEREBRAL VASCULAR ACCIDENTS
- Does a relationship exist between stroke and MVP?
- Potential mechanisms
- Recommendations for antithrombotic therapy
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS