Download Mitral valve prolapse: diagnosis, treatment and natural

Medicina (Kaunas) 2005; 41(4)
325
Mitral valve prolapse: diagnosis, treatment and natural course
Regina Jonkaitienė, Rimantas Benetis1, Rūta Ablonskytė-Dūdonienė, Renaldas Jurkevičius
Clinic of Cardiology, 1Clinic of Cardiac Surgery, Kaunas University of Medicine, Lithuania
Key words: mitral valve prolapse, natural course, complications, surgical treatment, mitral
valve repair.
Summary. This article analyzes data obtained from the medical records of the patients with
primary mitral valve prolapse. The study population was the patients admitted to Kaunas
University of Medicine Heart Center (KUMHC) between 1999 and 2003. The objective of our
study was to analyze the natural course of mitral valve prolapse, complications and their frequency,
treatment strategy in KUMHC, as well as to review the results of surgical treatment.
We gathered data from the medical records of 160 patients and analyzed their age, medical
history, complications, comorbidities, functional status and echocardiographic parameters.
Patients who underwent mitral valve surgery were followed 7.9±8.4 months after procedure.
On average, 32±14 patients with primary mitral valve prolapse were treated at KUMHC
annually. Their mean age was 48.4±16.5 years, 44.4% of them were male. The most frequent
complications of mitral valve prolapse were ³II° mitral regurgitation (78.4%), various cardiac
arrhythmias (68.1%) and heart failure of ³II NYHA class (79%). Surgical treatment was
recommended for 64 (40%) KUMHC patients with primary mitral valve prolapse. Surgical
treatment was applied in 44 (28.1%) of study patients. The patients, who were recommended
surgical treatment, were older (mean age 53.2±11.9 years, p<0.05) and predominantly male
(62.5%, p<0.05) as compared to medically managed patients. The heart failure (62.5% had
NYHA class III or IV), severe mitral regurgitation (95.3% had mitral regurgitation of ³III°) and
worse left ventricle function (15% had ejection fraction of <50%) were more frequent in this
group as compared to medically managed patients (all p<0.05). During the last five years the
number of hospitalized patients with primary mitral valve prolapse increased 3.2 times, the number
of mitral valve surgical procedures among these patients increased 2.8 times, and the number of
mitral valve repair increased 15.8 times. 56.8% of patients had uncomplicated postoperative
course. The most frequent postoperative complication was new arrhythmias and/or conduction
disturbances. 1 patient died in early postoperative period. There was significant decrease in left
ventricle and left atrium size and the severity of mitral regurgitation 2 to 6 months after mitral
valve surgery. These positive changes remained during all study period.
Taking in the consideration the large number of mitral valve repair procedures and good
outcomes, the low postoperative mortality of the surgical mitral valve prolapse treatment in
KUMHC, we can strongly recommend surgical treatment for the patients with severe mitral
regurgitation secondary to mitral valve prolapse.
Introduction
Mitral valve prolapse (MVP) is an abnormal movement of one or both mitral valve leaflets (morphologically normal-appearing, or redundant and thickened) into the left atrium during systole (Fig. 1). Synonyms for MVP include Barlow syndrome or disease,
billowing mitral valve, floppy mitral valve, myxomatous mitral valve, systolic/mitral click–murmur syndrome. MVP can be primary or secondary. Primary
MVP appears in otherwise healthy heart and is asso-
ciated with genetic factors. Secondary MVP can
develop in the patients with coronary heart disease,
rheumatic heart disease, etc. (1). Mitral valve prolapse
was first described in 1966 by Barlow and Bosman
(2). Since then medical literature offers variable and
often controversial data about MVP epidemiology,
natural course, complications, diagnostics and treatment strategies.
Mitral valve prolapse is quite heterogenous disease according to its natural course. Populational stu-
Correspondence to R. Ablonskytė-Dudonienė, Clinic of Cardiology, Kaunas University of Medicine, Eivenių 2,
50009 Kaunas, Lithuania. E-mail: [email protected]
326
Regina Jonkaitienė, Rimantas Benetis, Rūta Ablonskytė-Dūdonienė, Renaldas Jurkevičius
A
B
Fig. 1. Normal mitral valve (A) and posterior leaflet prolapse (B)
AL – anterior leaflet of mitral valve; PL – posterior leaflet; PA – pulmonary artery; Ao – aorta.
dies show that more than one half of the patients with
MPV are asymptomatic and usually have benign
course of the disease. Their overall morbidity and mortality is similar to general population (3). However,
in the remaining portion of cases MVP may be associated with severe cardiovascular complications, such
as progressive mitral regurgitation, arrhythmias, heart
failure, increased risk of infective endocarditis and
7.8% of the patients with MVP require mitral valve
surgery (3). Different authors from various centers
had provided variable data concerning MVP course,
complications and their frequency (3–7). Any clinical or epidemiological studies on MVP have not been
conducted in Lithuania so far, hence the MVP clinical course, treatment strategy and results, own surgical treatment experience have not been analyzed.
There are no generally accepted criteria for the
optimal timing of mitral valve surgery in MVP. Indications for the MPV surgical treatment in Kaunas
University of Medicine Heart center (KUMHC) were
outlined following ACC/AHA Guidelines for the
Management of Patients with Valvular Heart Disease
(published in 1998 (1)) and ESC Working Group Recommendations on the Management of the Asymptomatic Patient with Valvular Heart Disease (published
in 2002 (8)). These guidelines are based upon extensive worldwide experience and the results of the mitral regurgitation surgical treatment. However, majority of the studies on which the guidelines are based
have not separated patients with mitral valve prolapse.
Moreover, majority of the specialists (9, 10) note that
indications for the surgical treatment of mitral valve
prolapse as well as the timing of the surgery should
be based upon the experience and the results in particular hospital. Therefore, analysis of surgical experience in our medical center is important.
The objective of this study was to analyze the natural course of mitral valve prolapse, its complications
and their frequency, the management strategy, as well
as experience and results of the surgical treatment at
KUMHC.
Patients and methods
The records of a total of 160 subjects (mean age
48.4±16.5 years, 44.4% male) with primary MVP
hospitalized in KUMHC from 1999 to 2003 were analyzed. The diagnosis of MVP was made by the physical examination (midsystolic or telesystolic click
with a systolic murmur on the heart auscultation) and
two-dimensional echocardiography. Two-dimensional
echocardiography was performed in all patients. Then
transesophageal two-dimensional echocardiography
was performed in 31.2% of study patients to confirm
the diagnosis. Echocardiographic diagnosis of MVP
was made using Freed et al. criteria (6).
Patients with the secondary MVP due to coronary
heart disease or rheumatic heart disease were excluded. Associated incidental coronary artery disease
was not an exclusion criterion.
In the medical records of patients with primary
MVP we looked at the age, past medical history,
Medicina (Kaunas) 2005; 41(4)
327
Mitral valve prolapse: diagnosis, treatment and natural course
comorbidities, complications of mitral valve prolapse,
as well as patient’s functional state according to New
York Heart Association (NYHA) classification, and
echocardiographic measurements (such as end-diastolic left ventricle dimension (EDLVD), left atrium diameter (LA), left ventricle ejection fraction (EF) by
Simpson’s method, the degree of mitral regurgitation).
We also evaluated the change of two-dimensional
echocardiographic findings over five years in operatively managed patients. Patients who underwent mitral
valve surgery were followed up in average for 7.9±8.4
months (from 2 to 39 months) after procedure.
Statistical analysis was performed using STATISTICA 5.0 software. Quantitative values were mean
and standard deviation. The comparison of data from
groups of recommended either medical management
or surgical, as well as the group of operated patients
versus those who refused surgery was performed using Student’s t-test for the independent samples. Comparison between two-dimensional echocardiographic
findings before and after surgery was made using Student’s t-test for dependent samples. The difference
between two variables was considered statistically
significant if p value was equal or less than 0.05. All
p tests were two-sided.
Results
Data analysis shows that between 1999 and 2003,
32±14 patients with primary mitral valve prolapse
were hospitalized annually in KUMHC. Surgical treatment was recommended to 64 (40%) patients. Surgery was performed in 45 (28.1%) of all MPV patients treated in KUMHC during study period, which
was annually 9±6.4 of these patients. 19 (29.7%) of
all patients who were referred for an operative treatment refused surgery.
The rate of the hospitalizations due to MVP increased 3.2 times (7.5% to 23.7%) in 5-year period
since 1999. And the number of patients who were referred for the heart surgery increased 3.3 times (from
16.7% to 55.3%). The number of patients who underwent surgery was 2.8 times bigger in 2003 than in
1999 (Fig. 2).
The study population was divided into 4 groups:
· patients to whom medical management was recommended,
· patients to whom surgical management was recommended,
· the group of patients who underwent surgery,
· and the group of patients who refused surgery.
The summary of the clinical characteristics of these
4 groups is shown in Table 1.
All study patients were further divided into two
groups according to their NYHA functional status
(NYHA I–II and NYHA III–IV) and into four groups
according to the degree of mitral regurgitation. In order to estimate the rate of progression of mitral regurgitation and heart failure in MVP patients, the mean
age was calculated and compared in all subgroups
mentioned above. 103 (64.4%) patients were assigned
to NYHA I–II group, their mean age was 42.0±14.8
years; respectively 57 (35.6%) patients were assigned
to NYHA III–IV group, mean age 59.8±13.1 years
(p<0.0001). Mitral regurgitation of I° was diagnosed
to 32 (20.9%) patients, their mean age was 55.1±13.1
years; II° mitral regurgitation – 44 (28.7%) patients,
20
20
50
40
00
30
-20
20
-40
10
0
-60
1999
2000
2001
2002
2003
patients with MVP)
Percent (from patients with MVP
hospitalized during particular year)
60
Percent
(from
hospitalized
(from Percent
hospitalized
patients
with MVP)
40
40
70
Surgery
recommended
(primary axis)
Underwent
surgery
(primary axis)
Rejected
surgery
(primary axis)
Hospitalized
with MVP
(secondary
axis)
Year
Fig. 2. Management strategy variation in patients with mitral valve prolapse during 1999–2003
Medicina (Kaunas) 2005; 41(4)
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Regina Jonkaitienė, Rimantas Benetis, Rūta Ablonskytė-Dūdonienė, Renaldas Jurkevičius
Table 1. Clinical characteristics of the patients with primary mitral valve prolapse
Features
Male
Female
Age (mean ± SD)
Total
n=160
(%)
Medical
management
group
n=96 (%)
Group of
patients
referred
for surgical
treatment
n=64 (%)
71 (44.4)
89 (55.6)
48.4±16.5
31 (32.3)
65 (67.7)
43.9±17.7
40 (62.5) 0.0002*
24 (37.5) 0.0002*
55.1±11.8 <0.0001*
Medical history:
Hypertension
63 (39.9){a} 32 (33.7){b} 31 (49.2){c}
Arrhythmias (any)
109 (68.1) 67 (69.8)
42 (65.6)
AF/AU
58 (36.2)
29 (30.2)
29 (45.3)
PVB
49 (30.6)
32 (33.3)
17 (26.6)
PVT
4 (2.5)
3 (3.1)
1 (1.6)
PSVT
13 (8.1)
13 (13.5)
0
Heart block/pacemaker
7 (4.4)
6 (6.25)
1 (1.6)
Marfan syndrome
2 (1.2)
1 (1.0)
1 (1.6)
Coronary artery disease
21 (13.1)
10 (10.4)
11 (17.2)
Aortic valve disease
6 (3.7)
2 (2.1)
4 (6.2)
Infect. endocarditis (total)
12 (7.5)
2 (2.1)
10 (15.6)
Active endocarditis
9 (5.6)
2 (2.1)
7 (10.9)
NYHA functional class
1
2
3
4
32 (20.0)
71 (44.4)
50 (31.2)
7 (4.4)
32 (33.3)
49 (51.0)
14 (14.6)
1 (1.0)
0
22 (34.4)
36 (56.2)
6 (9.4)
p
Surgical
treatment
group
n=44**
(%)
Group of
patients
who
rejected
surgery
n=19 (%)
27 (61.4)
17 (38.6)
53.2±11.9
12 (63.1)
7 (36.8)
54.7±7.1
0.06
0.59
0.05*
0.42
0.70
0.03*
0.23
0.60
0.20
0.18
0.001*
0.02*
19 (43.2)
25 (56.8)
20 (45.4)
9 (20.4)
0
0
1 (2.3)
1 (2.3)
7 (15.9)
2 (4.5)
8 (18.2)
6 (13.6)
<0.0001*
0.03*
<0.0001*
0.01*
0
16 (36.4)
22 (50.0)
6 (13.6)
0
8 (42.1)
11 (57.9)
0
0.14
0.008*
0.02*
21 (52.5){l}
14 (35.0){l}
5 (12.5){l}
0{l}
5 (26.3)
11 (57.9)
3 (15.8)
0
p
0.88
0.88
0.61
11 (61.1){k} 0.20
17 (89.5) 0.01*
9 (47.4)
0.88
8 (42.1)
0.07
1 (5.3)
0.14
0
0
0.54
0
0.54
5 (26.3)
0.36
2 (10.5)
0.39
2 (10.5)
0.49
1 (5.3)
0.30
0.65
0.56
0.09
LV ejection fraction
³60%
50–59%
40–49%
<40%
51 (36.4){d} 25 (31.2){e} 26 (43.3){f}
77 (55.0){d} 52 (65.0){e} 25 (41.7){f}
12 (8.6){d}
3 (3.7){e}
9 (15.0){f}
{d}
{e}
0
0
0{f}
Degree of mitral regurgitation
none
1°
2°
3°
4°
1 (0.6){g}
1 (1.1){h}
{g}
32 (20.9)
32 (35.9){h}
44 (28.7){g} 41 (46.1){h}
40 (26.1){g} 12 (13.5){h}
36 (23.5){g} 3 (3.4){h}
0
0
3 (4.7)
28 (43.7)
33 (51.6)
0.42
<0.0001*
<0.0001*
0.0001*
<0.0001*
0
0
1 (2.3)
16 (36.4)
27 (61.4)
0
0
1 (5.3)
12 (63.1)
6 (31.6)
0.52
0.05*
0.04*
Affected leaflet
Posterior
Anterior
Both
29 (19.9){i} 10 (12.2){j}
76 (52.0){i} 55 (67.1){j}
41 (28.1){i} 17 (20.7){j}
19 (29.7)
21 (32.8)
24 (37.5)
0.008*
0.0001*
0.02*
14 (31.2)
12 (27.3)
18 (40.9)
5 (26.3)
8 (42.1)
6 (31.6)
0.69
0.24
0.50
0.06
0.10
0.76
n – number of the patients; p – level of statistical significance; AF/AU – atrial fibrillation or undulation; PVB – premature
ventricular beats; PVT – paroxysmal ventricular tachycardia; PSVT – paroxysmal supraventricular tachycardia; NYHA –
New York Heart Association classification; LV – left ventricle; {a} – n = 158; {b} – n = 95; {c} – n = 63; {d} – n = 140; {e} – n
= 80; {f} – n = 60; {g} – n = 153; {h} – n = 89; {i} – n = 146; {j} – n = 82; {k} – n = 18; {l} – n = 40; * statistically significant
difference between comparable groups; ** one patient had postoperative diagnosis other than mitral prolapse, so he was
not included into further analysis.
mean age 47.2±17.0 years (comparing I° and II° mitral regurgitation groups p=0.03), III° mitral regurgitation – 40 (26.1%) patients, mean age 33.6±11.6 years
(comparing II° and III° mitral regurgitation groups
p=0.0001), IV° mitral regurgitation – 36 (23.5%) patients, mean age 57.2±13.5 years (comparing III° and
IV° mitral regurgitation groups p<0.0001).
Operative data of the patients with primary MVP
are shown in Table 2. Table 3 shows data about the
early postoperative period. Analysis of annually performed heart operations revealed that number of mitral valve repair surgeries was increasing, and from
1999 to 2003 increased by 41.6% (from 2.8% to
44.4%) (Fig. 3).
Medicina (Kaunas) 2005; 41(4)
Mitral valve prolapse: diagnosis, treatment and natural course
Table 2. Operative data of the patients with
mitral valve prolapse
Table 3. Incidences during early postoperative
period
Total,
n (%)
Features
Number of surgery
44
Mitral anuloplasty
27 (61.4)
Tricuspid valve repair
15 (34.1)
Other operation in conjunction
Coronary artery bypass
Aortic valve replacement
8 (18.2)
4 (9.1)
4 (9.1)
Reoperation
1 (2.3)
329
Total,
n (%)*
Incidences
Uncomplicated
27 (61.4)
Complicated:
Death
New arrhythmias /
conduction disturbances
Cardiogenic shock
Resternotomy due to bleeding
Sepsis
Pneumothorax
17 (38.6)
1 (2.3)
9 (20.4)
1 (2.3)
2 (4.5)
3 (6.8)
1 (2.3)
n – number of patients;
* total number of surgery patients was 44.
n – number of patients.
Percent
50
44.4
40
30.5
30
20
10
13.9
8.3
2.8
0
1999
2000
2001
2002
2003
Years
Fig. 3. Changes of the relative number of mitral valve repairs
Analysis of two-dimensional echocardiography
measurements up to 40 months after surgery revealed
that EDLVD significantly decreased over 2–6 months
after surgery (–8.8±3.7 mm, p<0.0001). The same
trend was found with LA dimensions (long dimension decreased by –6.8±3.5 mm, p=0.0002; short dimension by –4.4±5.9 mm, p=0.04)). Left ventricular
EF also decreased but remained normal. The greatest
change was noticed 2 to 6 months after surgery
(–8.5±5.1%, p=0.0005, or from 56.0±7.6%. to 51.2±
5.3%). Later left ventricular EF did not change significantly. 40 months after surgery mean EF was
50.0%. Figure 4 shows dynamics of two-dimensional
Medicina (Kaunas) 2005; 41(4)
echocardiography measurements after surgery. Change of the mitral regurgitation severity after surgery is
reflected in Figure 5.
Discussion
This retrospective study analyzed data of the patients with MVP who already had cardiac symptoms
severe enough to be admitted to the hospital. Therefore, study population is not random and reflects only
the group of patients with primary MVP who were
symptomatic. Consequently, these patients were likely
to have much higher incidence of complications, as
well as requirement for surgical treatment compared
Regina Jonkaitienė, Rimantas Benetis, Rūta Ablonskytė-Dūdonienė, Renaldas Jurkevičius
80
100
100
70
90
90
60
80
80
70
70
50
40
60
60
30
50
50
20
40
–1
1
2–6
7–12
Months after sugery
Long dimension
of LA
EF (perc.)
EF
(perc.)
LA dimension, EDLVD (mm)
330
Short dimension
of LA
EDLVD
EF
13–40
Fig. 4. Postoperative changes of two-dimensional echocardiographic measurements
MR degree
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
–0.5
–1
-1
1
1
2–6
7–12
2-6
7-12
Months after sugery
13–40
13-40
Fig. 5. Postoperative change of the degree of mitral regurgitation
to the rest of the patients with MVP. Recent worldwide
populational studies showed that the prevalence of
MVP in general population was rather low: 0.6–2.4%
(6, 11).
The hospitalization rate, the need for surgical treatment and the number of mitral valve surgeries due to
MVP are growing every year, despite low MVP prevalence. They increased near 3 times over the past 5
years. This can be attributed to the improvement in
the technique of cardiac surgery in KUMHC. The
frequency of the surgical mitral valve repair is increasing every year. Moreover, the opinion of the cardiologists about surgical treatment of MVP has changed,
and because of the new clinical research (9) mitral
valve surgery is more frequently recommended for
asymptomatic and minimally symptomatic patients
with severe mitral regurgitation. These patients are more
likely to have better long-term survival than symptomatic patients (NYHA functional class III or IV).
In our study the mean age of patients with primary
MVP was 48.4 years. Etiology of primary MVP is
associated with the genetic factors (12–14). The natural course of the disease is rather benign. Symptoms
and complications usually appear only after 40 or 50
years of age. The patients to whom surgical treatment
was recommended were significantly older than the
Medicina (Kaunas) 2005; 41(4)
Mitral valve prolapse: diagnosis, treatment and natural course
patients in medical management group (mean age 55.1
vs. 43.9 years, respectively; p<0.0001). It means that
even when complications appear approximately 10
years pass till surgery is required. Symptomatic MVP
was equally distributed between both sexes, but the
need for heart surgery due to complications of MVP
was bigger in males (62.5% of patients to whom heart
surgery was recommended were males). In comparison, only 32.3% were males in medical management
group (p=0.0002). These results correspond to the
ones of the other researchers (15, 16) who had also
observed that the patients older than 45, the males
and those with the severe mitral regurgitation had a
higher risk for MVP complications.
The most frequent complication of mitral valve
prolapse is the progression of mitral regurgitation (3).
It causes dilatation and dysfunction of left atrium and
left ventricle, cardiac arrhythmias, and later heart failure, increased risk of infective endocarditis. Second
degree or more severe mitral regurgitation was found
in 78.4% of the patients. Common complication of
MVP was cardiac arrhythmias. They were diagnosed
in 68.1% of the patients. The most frequent types of
cardiac arrhythmias were: atrial fibrillation (36.2%)
and premature ventricular complexes (30.6%). Another common complication was a heart failure. NYHA
functional class III or IV was found in 35.0%. 44.0%
of the patients had NYHA functional class II. Infective
endocarditis was more prevalent in MVP patients than
in the general population. The prevalence of infective
endocarditis in general population of Lithuania is
0.004% (17). 7.5% of study patients had infective
endocarditis at some point of their lives. 5.6% had
endocarditis during study period (active endocarditis).
Two patients (1.2%) who had past history of MVP,
needed mitral valve replacement surgery during study
period due to complications of the infective endocarditis of mitral valve. Other MVP complications were
quite rare. 4.4% of the patients due to disturbances of
the heart conduction required pacemaker placement.
2.5% of the patients had thromboembolic events. Arterial hypertension as comorbidity was found in 39.9%
of patients and commonly it was mild.
Comparison of the mean age of study patients according to their NYHA functional status revealed that
the patients who had NYHA functional class I–II were
significantly younger than the patients who had NYHA
functional class III–IV (mean age 42.0 vs. 59.8 years,
respectively; p<0.0001). We can premise that in case
of complicated MVP the heart failure progress usually
is rather slow. First heart failure symptoms usually
appear only after 40 or 50 years of age. Approximately
Medicina (Kaunas) 2005; 41(4)
331
15 more years passes until heart failure symptoms become severe. We did not find consistency that the severity of mitral regurgitation would increase with age
while analyzing the mean age of study patients according to the degree of their mitral regurgitation. The
mean age of the patients with mitral regurgitation of
I° and IV° was similar (55.1 vs. 57.2 years, respectively). It can be concluded that progress of heart failure
was not always associated with the increasing mitral
regurgitation. Other MVP complications (e.g. arrhythmias or conduction disturbances) as well as comorbidities, especially hypertensive cardiopathy and coronary heart disease also played a significant role in the
development of heart failure.
Anterior leaflet prolapse was diagnosed in 52% of
the study patients, bileaflet prolapse in 28.1%, and
posterior leaflet prolapse in 19.9%. Therefore, anterior
leaflet prolapse was 2.6 times more prevalent than
posterior leaflet and 1.8 times more prevalent than
bileaflet prolapse. Posterior leaflet and bileaflet prolapse were significantly more prevalent in the group
of patients to whom surgical treatment was recommended as compared to medical management group (29.7%
vs 12.2%, p=0.008 and 37.5% vs. 20.7%, p=0.02;
respectively). Anterior leaflet prolapse was less prevalent in the surgical treatment group (32.8% vs.
67.1% in medical management group; p=0.0001).
It is described in the medical literature that in primary MVP posterior leaflet is affected more frequently
(9, 10). The lesion of anterior leaflet is characteristic
of rheumatic heart disease (1). It is not clear why anterior leaflet prolapse was more prevalent than posterior leaflet prolapse in our study patients. Possible
explanation could be that due to saddle-shaped configuration of the mitral valve, as it was shown with
three-dimensional echocardiography (18), prolapselike picture could be seen in certain two-dimensional
echo cardiographic views, and it can be mistaken for
mitral prolapse (false positive results). More precise
diagnostic method, transesophageal two-dimensional
echocardiography was more frequently used in the
surgical treatment group than in medical management
group (50.8% vs. 18.7%, respectively; p<0.0001).
Therefore, false positive results are less likely in the
surgical treatment group.
Current guidelines for indications for the surgical
treatment in mitral regurgitation and for the optimal
timing of corrective surgery are recommended considering the presence or absence of symptoms, EF, EDLVD,
LA enlargement, the presence of pulmonary hypertension. Patients to whom surgical treatment was recommended had worse EF, more severe mitral regurgita-
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Regina Jonkaitienė, Rimantas Benetis, Rūta Ablonskytė-Dūdonienė, Renaldas Jurkevičius
tion, and were more symptomatic than the patients in
medical management group. EF less than 50% was
found in 15% of the first group patients vs. 3.7% of
patients in the second group (p=0.02). Mitral regurgitation of III° or worse was prevalent 95.3% and
16.8% respectively (p=0.0001). NYHA functional class
III or IV was found significantly more prevalent in
the group of patients who were recommended surgical
treatment than in medical management group (62.5
vs. 16.7%; p<0.0001). 43.3% of the patients who were
referred for the surgical treatment and 52.5% of the
patients who underwent surgery had EF³60%, i. e.
those patients underwent surgery with normal left
ventricular function. 41.7% and 35.0% of the patients
in before mentioned groups, respectively, had EF 50–
60%. These patients underwent surgery with slightly
impaired left ventricular function. Only 15.0% of the
patients that were referred for the surgical treatment
and 12.5% of the patients that agreed to it had EF
<50%. These patients underwent surgery with poor
left ventricular function, so the surgery was overdue.
The age, NYHA functional class, the measurements of two-dimensional echocardiography of the
surgically treated patients, the timing of the mitral valve surgery as well as the surgical methods in KUMHC
are the same as in developed centers worldwide (9,
10). Both worldwide and in KUMHC mitral valve
surgery has been performed more frequently in the
symptomatic patients. 63.6% of the subjects in our
surgery group had NYHA functional class III or IV.
In the latest publications one can find more and more
data about superior long-term results of the mitral valve surgery in asymptomatic and minimally symptomatic patients. More symptomatic patients have bigger
chance of worse long-term results and shorter longterm survival than asymptomatic and minimally symptomatic patients.
During the last five years the number of mitral
valve repairs is growing steadily and has increased
15.8 times. Mitral valve repair was combined with
mitral anuloplasty in 61.4% of the patients. Mitral valve surgery was combined with tricuspid valve repair
in more than 30% of patients. It was done at the same
time as coronary artery bypass surgery in 9.1% of the
patients. And it was done with aortic valve replacement in 9.1% of the patients.
61.4% of the patients had uncomplicated postoperative course. The most frequent postoperative complications were new cardiac arrhythmias and/or conduction disturbances (20.4%). Other complications (cardiogenic shock, resternotomy due to major bleeding,
pneumothorax) were documented in 9.1% of the sur-
gery group patients. One patient died on the third day
after mitral valve repair. His postoperative course was
complicated by cardiogenic shock, progressive heart
failure. Consequently, the early postoperative (30 day)
mortality after mitral valve surgery in KUMHC was
2.3% during study period, so it was similar to other
centers – 0.3% (19), 1.02% (9), 2.6% (20).
Risk factors for increased cardiovascular mortality
in patients with MVP were found to be mitral regurgitation of ³II°, EF<50% (3, 19). Predictors of higher
cardiovascular morbidity are mitral regurgitation,
LA³40 mm, atrial fibrillation, patient’s age ³50 years
(3, 19).
We have reviewed the postoperative change of twodimensional echocardiography measurements such as
the degree of mitral regurgitation, EF, LA diameter,
EDLVD. The mean degree of mitral regurgitation prior
to the surgery in the surgical treatment group was 3.6±
0.5. It decreased to 0.86±0.9 right after surgery (p<
0.0001). As shown in Figure 5 during the late postoperative period the mean degree of mitral regurgitation
in the surgical treatment group was increasing slightly
but did not exceed 1.2±0.4 and remained significantly
lower than before the surgery during all study period.
In various publications it has been noted that EF
increased after surgery (9, 10, 20). Analysis of our
results revealed that left ventricular EF slightly decreased after surgery but still remained normal. The peak
mean difference of –8.5±5.1% (from 56.0±7.6% to
51.2±5.3%; p=0.0005) was observed 2 to 6 months
after surgery. Left ventricular EF did not change significantly later, and 40 months after surgery mean EF
was 50.0%.
EDLVD significantly decreased 2 to 6 months after
surgery (–8.8±3.7 mm; p<0.0001) and LA dimensions
did as well (long dimension –6.8±3.5, p=0.0002; short
dimension –4.4±5.9, p=0.04). Mean EDLVD in the
surgical treatment group remained normal all study
period, and 13 to 40 months after surgery was 44.5±0.7
mm. LA mean short dimension in the surgical treatment group decreased to normal over 2 to 6 months
after surgery and remained the same all study period
(13 to 40 months after surgery was 42.5±0.7 mm). At
the same time long dimension of LA did not return
back to the normal even though it decreased by –
9.3±5.4 mm (p=0.008) 7 to 12 months after surgery.
Looking at these results we can state that the remodeling of the left ventricle and the left atrium occurred
2 to 6 months after surgery and remained stable during
all study period, i.e. up to 40 postoperative months.
Almost one third of the patients who were referred
for the surgical treatment rejected surgery. The comMedicina (Kaunas) 2005; 41(4)
Mitral valve prolapse: diagnosis, treatment and natural course
parison of clinical characteristics between the groups
of the patients who underwent surgery and those who
resigned it revealed that both groups had the same
demographic data (sex, age) as well as similar comorbidities. Though III° mitral regurgitation was more
prevalent in the group that rejected surgery (63.1 vs.
36.4%; p=0.05), both groups had the same NYHA
functional class and EF. Therefore, we can conclude
that the reasons to reject surgery were subjective and
dependent on person’s fear of surgery itself as well as
its complications. This fear in turn is caused by the
lack of information about natural course of this disease, treatment options and good results of the surgical
treatment.
Conclusions
1. Though symptomatic primary mitral valve prolapse is not a common disease the hospitalization rate
and number of heart surgeries due to mitral valve prolapse is growing steadily every year.
333
2. The most common causes of the hospitalization
in MVP patients were: development of mitral regurgitation, severe mitral insufficiency, cardiac arrhythmias
and heart failure. More than one third of patients with
mitral valve prolapse required heart surgery.
3. Number of mitral valve repairs is growing steadily in KUMHC every year.
4. The remodeling of the left ventricle and the left
atrium occurred during six months after mitral valve
surgery. At that time the echocardiography measurements of left heart were decreasing, mitral regurgitation was not increasing and these positive changes
remained during all study period (40 months).
5. Taking in the consideration the large number of
mitral valve repair procedures and good outcomes,
the low postoperative mortality, as well as regression
of the left heart dilatation after surgery, we can strongly
recommend surgical treatment in KUMHC for the patients with severe mitral regurgitation secondary to
mitral valve prolapse.
Mitralinio vožtuvo prolapso diagnostikos, gydymo ir eigos ypatybės
Regina Jonkaitienė, Rimantas Benetis1, Rūta Ablonskytė-Dūdonienė, Renaldas Jurkevičius
Kauno medicinos universiteto Kardiologijos klinika, 1Kardiochirurgijos klinika
Raktažodžiai: mitralinio vožtuvo prolapsas, eigos ypatybės, komplikacijos, chirurginis gydymas, mitralinio
vožtuvo plastika.
Santrauka. Straipsnyje nagrinėjami duomenys apie 1999–2003 metais Kauno medicinos universiteto klinikų
Širdies centre dėl pirminio mitralinio vožtuvo prolapso gydytų pacientų skaičių, jų klinikines charakteristikas,
chirurginį gydymą.
Darbo tikslas. Išanalizuoti pirminio mitralinio vožtuvo prolapso eigos ypatybes, komplikacijas bei jų dažnį,
Kauno medicinos universiteto klinikų Širdies centre taikomą gydymo taktiką, chirurginio gydymo rezultatus
bei patirtį.
Išanalizuota 160 pacientų medicininė dokumentacija: įvertintas tiriamųjų amžius, anamnezė, komplikacijos
ir gretutinės ligos, funkcinė būklė, echokardiografiniai rodmenys. Operuotų ligonių echokardiografinių rodmenų
dinamika stebėta 7,9±8,4 mėnesio po mitralinio vožtuvo korekcijos operacijos.
Kauno medicinos universiteto klinikų Širdies centre kasmet gydyta 32±14 pacientų, kuriems diagnozuotas
pirminis mitralinio vožtuvo prolapsas, jų amžius – 48,4±16,5 metų, 44,4 proc. šių ligonių – vyrai. Dažniausios
mitralinio vožtuvo prolapso komplikacijos buvo II arba didesnio laipsnio mitralinio vožtuvo nesandarumas
(78,4 proc.), įvairūs širdies ritmo sutrikimai (68,1 proc.), II arba didesnio laipsnio NYHA funkcinės klasės
širdies nepakankamumas (79 proc.). Chirurginis gydymas rekomenduotas 64 (40 proc.) Kauno medicinos
universiteto klinikų Širdies centre gydytiems pacientams, kuriems diagnozuotas pirminis mitralinio vožtuvo
prolapsas. Operuoti 44 (28,1 proc.) tiriamieji. Lyginant su konservatyvaus gydymo grupe, didesnę dalį pacientų,
kuriems rekomenduotas chirurginis gydymas, sudarė vyrai (62,5 proc.). Šie pacientai buvo vyresni (amžiaus
vidurkis – 55,1±11,8 metų), jiems buvo ryškesni širdies nepakankamumo simptomai (62,5 proc. – III–IV
NYHA funkcinės klasės), didesnio laipsnio mitralinė regurgitacija (95,3 proc. regurgitacija buvo III ir didesnio
laipsnio) ir blogesnė kairiojo skilvelio funkcija (15 proc. nustatyta išstūmimo frakcija mažiau nei 50 proc.)
(visų minėtų rodmenų skirtumo tarp grupių p<0,05). Per pastaruosius penkerius metus dėl mitralinio vožtuvo
prolapso hospitalizuotų pacientų skaičius padidėjo 3,2 karto, operacijų skaičius šiems pacientams – 2,8 karto,
Medicina (Kaunas) 2005; 41(4)
334
Regina Jonkaitienė, Rimantas Benetis, Rūta Ablonskytė-Dūdonienė, Renaldas Jurkevičius
mitralinio vožtuvo plastikų skaičius – 15,8 karto. Pooperacinė eiga 56,8 proc. pacientų buvo sklandi. Dažniausia
pooperacinė komplikacija – nauji širdies ritmo ir laidumo sutrikimai. Ankstyvuoju pooperaciniu laikotarpiu
mirė vienas pacientas. Per 2–6 mėnesius po mitralinio vožtuvo operacijos žymiai sumažėjo kairiojo skilvelio
ir kairiojo prieširdžio matmenys bei mitralinės regurgitacijos laipsnis ir šie teigiami pakitimai išliko visą
stebėjimo laikotarpį.
Įvertinus mažą pooperacinį mirštamumą, chirurginio gydymo efektyvumą, mitralinio vožtuvo plastikų santykinį dažnį ir pooperacinį kairiosios širdies dilatacijos regresavimą, chirurginį gydymą Kauno medicinos
universiteto klinikų Širdies centre galima pagrįstai rekomenduoti pirminiu mitralinio vožtuvo prolapsu sergantiems pacientams, nustačius didesnio laipnio mitralinę regurgitaciją.
Adresas susirašinėti: R. Ablonskytė-Dūdonienė, KMUK Kardiologijos klinika, Eivenių 2, 50009 Kaunas
El. paštas: [email protected]
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Received 29 December 2004, accepted 12 April 2005
Straipsnis gautas 2004 12 29, priimtas 2005 04 12
Medicina (Kaunas) 2005; 41(4)