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Mitral valve prolapse : Finally . . . facts are trying to prevail over fiction !

Posted Mar 12 2011 3:18am
 

Ever since  Barlow reported  this entity , mitral valve prolapse was made  a fascinating disease of  the heart . Cardiologist’s honeymoon with this disorder lasted  for too long   . . .  four  decades ?. It is probably the most  common valvular disease physicians diagnose .The importance of which was  exaggerated  and at one point of time  the term was  getting  abused.

So the criterias  were made strict in later decades . Now unless MR is present along  with valve thickening MVPS should not be diagnosed.

Clinical presentation

  • Atypical chest pain
  • Palpitation
  • VPDS
  • Asymptomatic pre excitation
  • Anxiety state  including  panic attacks (More common after informing the patient about MVPS.) 
  •  

    Here is Monograph with excellent Images.I think this is available  free with Google Books. 

     

    MVPS -Auscultation

    Classical finding is mid systolic click with late systolic murmur.

    But in reality,   It can present with  any of the following

    • Early -mid systolic click,   with  murmur
    • Only murmur
    • Only click
    • No click,  no murmur -Only Echo evidence of MVPS
    • Clinical Click  but no MVPS in echo*

    The timing of click and murmur depends on the LV volume and the contractile force.Status of pap muscle is also important.There are studies which  show dehydration can induce MVPS and hydration corrects it  .One can guess the anatomical importance of this entity.

    Currently myxamatous  valves with clear prolapse with at least  grade 1 MR (Not the often reported trivial MR !) only be labelled as MVPS.All other  forms increase patient  anxiety , lead to unnecessary echocardiogram and of course promotes   physician    affluence !

    *Chordal clicks

    This was first described by Reid .A redundant  lengthy chrordae  folds unfolds  making a noise. Mitral valve as such may not  prolapse into LA and hence echocardiogram would be normal.

    Origin of chest pain in MVPS

    It is still a mystery  out there regarding the origin of chest pain in MVPS.

    It is thought to be a  mechanical pain from any of the following

    • Valve
    • Chordae
    • Myocardial stretch
    • Ischemic unlikely

    *currently it is  believed  to be a pain perception problem at cortical level.

    ECG

    • Non specific T wave inversions in inferior and lateral  leads common
    • Early repolarization patterns are common
    • WPW has a  rare association

    TMT

    False positives excercise stress tests are  reported  often .

    Echo

    • Echo  is to be primarily blamed for the  rampant diagnosis of this entity .
    • In deserving patients Echo is vital to define valve anatomy and MR assessment.
    • TEE will help us the exactly identify  culprit  scallops (Commonly P2 A2)  and facilitate the surgeon during repair.

    Coronary angiogram

    Many of the MVPS patients end up in inappropriate CAGs ( Decent term for guideline violation !).As a rule  , almost all will have normal coronary angiogram.

    Incidence of  Ventricular arrhythmias

    VPDs can be common in MVPS. ( Myocardial /Pap muscle Stretch induced ?)

    Sudden cardiac death is no more common than general population .So no worries .

    IE prophylaxis

    Generally not required unless significant MR present

    Management

    Most( 99.9%) will require no treatment . Only reassurance .This , if properly done shall be a one time process.There are many young persons  who report to the physicians  periodically to get reassured (Each time  spending 500 Rs !) This is called reassurance failure .Here , the  physician needs  to be urgently  changed.

    Many times , parents , spouse and relatives  will  require more  counselling  than the victim  of mvps !

    Few with progressive MR will need close monitoring  (Eg Associated Marfan )

    Tall,  thin individuals will require aortic size monitoring as well.

    Highly anxious persons will do well with beta blockers. Panicky individuals require sedatives as well.

    Very severe MR needs surgery .Surgeons   are encouraged  to repair a  myxamatous valve than to replace it .

    Secondary MVPS

    (MVPS in association with other structural disease  like Ischemic, RHD, Infective endocarditis are important pathological entities that need to be discussed separately )

    Final message

    MVPS is a benign disorder (Rather it can be called as  a variation in mitral valve morphology  ).  Only  In  a  fraction of  population it  can take a true  pathological course. Cardiologist and physicians should  disseminate this message widely to their draining population.Unfortunately  in the current state of affairs , MVPS  seem to be  less dangerous for human community than the  events  that   follow  the  misplaced diagnosis of this entity. In the name of health awareness  huge costs , time and resources are wasted in dealing with this almost  . . .non entity !


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